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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602258
Report Date: 10/16/2024
Date Signed: 10/16/2024 02:31:04 PM


Document Has Been Signed on 10/16/2024 02:31 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:LOVE & CARE RESIDENTIAL FACILITY IIFACILITY NUMBER:
374602258
ADMINISTRATOR:ERIC MELADFACILITY TYPE:
740
ADDRESS:603 MAYBRITT CIRTELEPHONE:
(760) 519-1449
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY:6CENSUS: 2DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Eric Melad - AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator Eric Melad who was informed of the purpose of today's visit. At the time of the visit there was two (2) staff and two (2) residents present. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. LPA observed outdoor furniture and shaded area for clients. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.



LPA reviewed staff files and training. Records review for Staff One (S1) and Staff Two (S2) revealed S1 and S2 have not conducted the required twenty (20) hours of annual training. A deficiency will be issued under Health and Safety Code 1569.625(b)(2) along with a plan of correction. Records review revealed S1 and S2 do not have a current CPR and first aide training on file. A deficiency will be issued under Health and Safety Code 1569.618(c)(3) along with a plan of correction. Two resident files were reviewed and possessed all required paperwork which included Admissions Agreement and updated Physician's Report. The listed administrator does not have a current and/or pending administrator certificate with the last administrator certificate expiring in 2023. A deficiency will be issued under Title 22 Regulation 87405(a) along with a plan of correction.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
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 10/16/2024 02:31 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 ASC, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above due to Staff One (S1) and Staff Two (S2) not having a current CPR training certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Licensee agrees to complete a valid CPR training and first aid training course and will submit proof of correction to LPA by the plan of correction date 11/01/2024.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having conducted the annual 20 hours of training for S1 and S2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Licensee agrees to have all staff complete the annually required 20 hours of training and submit a form indicating S1 and S2 has completed the required training. Licensee will submit proof of correction to LPA by the plan of correction date 11/01/2024.
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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 02:31 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 ASC, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in having Resident One (R1) PRN medication administration documented for the date and time PRN was taken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Licensee agrees to document when a PRN medication will be administered. Licensee agrees to conduct staff training on the regulation cited above and will submit proof of staff training to LPA by the plan of correction date 11/01/2024.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in conducting quarterly fire drills this year which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Licensee agrees to conduct a fire drill with staff and will submit proof of fire drill to LPA by the plan of correction date 11/01/2024. Licensee agrees to conduct quarterly fire drills for each staff.
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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 02:31 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 ASC, 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: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(1)(A)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (A) The preservation of medicines requires refrigeration, if the resident has no private refrigerator.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in having two (2) medication for Resident One (R1) that require refrigeration properly stored and inaccessible to residents in care. LPA observed the meds were in a refrigerator for perishable foods which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Licensee agrees to obtain a separate locked box so that the for the medications that require refrigeration can be stored, locked, and inaccessible to residents in care and kept separately from the food. Licensee will submit a photo of the refrigerator to the Department by the plan of correction date 11/01/2024.
Type B
Section Cited
CCR
87405(a)
87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on interview and records review it was found the facility does not have a current and certified administrator certificate. Administrator certificate expired in 2023 and records review revealed no pending or active certificate for S1 which poses a potential health safety or personal rights risk to residents in care.
POC Due Date: 11/01/2024
Plan of Correction
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Licensee agrees to send the renewal administrator certificate so that a qualified and current administrator at all times. Licensee will submit proof of renewal of administrator certificate to LPA by the plan of correction date 11/01/2024.
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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LOVE & CARE RESIDENTIAL FACILITY II
FACILITY NUMBER: 374602258
VISIT DATE: 10/16/2024
NARRATIVE
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Resident medication was centrally stored and locked in a closet located in a kitchen cabinet. LPA observed Resident One (R1) medication that require refrigeration stored in the kitchen's refrigerator with the facility's perishable foods and was accessible to residents in care. A deficiency will be issued under Title 22 Regulation 87465(h)(1)(A) along with a plan of correction. LPA reviewed medications prescribed to two (2) residents and found R1's PRN medication had been administered without the facility staff documenting the date and time the PRN medication was given. A deficiency will be issued under Title 22 Regulation 87465(d)(3) along with a plan of correction.

LPA reviewed the facility's emergency and disaster plan and infection control plan. Records review and interview with S1 revealed facility has not conducted the required quarterly fire drill this year. A deficiency will be issued under Health and Safety Code 1569.695(c) along with a plan of correction. LPA observed emergency supplies in the garage, a charged fire extinguisher, and first aid kit with all required items.

An exit interview was conducted where a copy of this report, LIC 809-D, LIC 811, and appeal rights was provided to Administrator Melad.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7