374602258-10-6-2023-18-AS-JSRS-CWCSH3-20231006135252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602258
Report Date: 10/06/2023
Date Signed: 10/06/2023 01:53:11 PM

Document Has Been Signed on 10/06/2023 01:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	LOVE & CARE RESIDENTIAL FACILITY II		FACILITY NUMBER:	374602258
ADMINISTRATOR:	ERIC MELAD		FACILITY TYPE:	740
ADDRESS:	603 MAYBRITT CIR		TELEPHONE:	(760) 519-1449
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92069
CAPACITY:	6	CENSUS: 3	DATE:	10/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	ERIC MELAD, Administrator		TIME COMPLETED:	01:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility for the purpose of an annual review. LPA was greeted by Administrator, Eric Melad and explained the purpose of the visit. A tour of the facility was conducted inside and out. At the time of visit, all three residents were home and one additional staff was present. The facility is approved for six (6) elderly residents ages 60 and over all of whom may be non-ambulatory. There is a hospice waiver for two (2) residents. The facility is a four (4) bedroom two (2) bathroom one story home. Each residents have their own bedroom. The fourth bedroom is reserved for staff. During the tour the following was observed: Resident bedrooms had the required furnishings and were observed to be in good condition. Bathrooms had required signage, hand rails, non-slip mats. Night-lights were observed in the hallways. Fixtures and furniture for an operational facility are present and in good repair. All passageways were free of obstructions, charged fire extinguishers and the fire alarm system was operable, medications are kept centralized and locked, hazardous items are kept inaccessible residents. Hot water was tested at 134 degrees Fahrenheit which is above the maximum temperature of 120 degrees Fahrenheit. Administrator adjusted the hot water temperature and will contine to monitor the temperature, adjusting it accordingly. Backyard area is free from obstructions. Kitchen/Food Service: LPA observed the entire kitchen, food is stored properly and dishes are clean and in good condition. There is a sufficient supply of perishable and non-perishable foods. Area was observed to be clean and functional. Care & Supervision: Facility has sufficient care staff employed. Administration: Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility. Drills are conducted regularly. The last drill was 3/20/2023.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/06/2023 01:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LOVE & CARE RESIDENTIAL FACILITY II	FACILITY NUMBER: 374602258
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review of R1, the licensee did not comply with the section cited above in [1] out of [3] residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/20/2023
	Plan of Correction
1 2 3 4	Administrator scheduled a doctor's appointment for Monday, 10/09/23 for R1 to have a physician's report completed. Administrator will email a copy of the report to the Department.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LOVE & CARE RESIDENTIAL FACILITY II	FACILITY NUMBER: 374602258
	VISIT DATE: 10/06/2023

NARRATIVE

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Record Review and Client/Staff Files: LPA reviewed current staff and all staff have has Criminal Background Clearance, current CPR/First Aid certification, and trainings are current. The Administrator's certificate expires 10/21/2023.

Resident records were reviewed and the following deficiency was observed:

-File review for R1 did not contain a current Physician's Report. The last Physician report was completed in 2020. LPA informed Administrator Physician's reports must be updated annually. Citation issued.

Physician reports for all other residents are current. All other documents in residents files were up to date.

Medication Review: LPA reviewed medication and medication log. Residents' medications are being dispensed according to physician's orders.

LPA provided a copy of the LIC 809, LIC 809D, and appeal rights to Administrator, Eric Melad during the exit interview.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

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