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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602712
Report Date: 07/23/2023
Date Signed: 07/23/2023 05:29:29 PM


Document Has Been Signed on 07/23/2023 05:29 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:ANNE'S PLACE IVFACILITY NUMBER:
374602712
ADMINISTRATOR:DEARME DOVERTEFACILITY TYPE:
740
ADDRESS:2870 WANEK ROADTELEPHONE:
(760) 233-5878
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:10CENSUS: 7DATE:
07/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Dearme Doverte, House ManagerTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an unannounced annual visit. LPA met with Dearme Doverte, House Manager and explained the purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. An overall tour of the facility was conducted inside and out. The facility is licensed for ten elderly non-ambulatory residents, and has an approved hospice waiver for six. There is approved bedridden fire clearance for up to ten. There are currently three residents on hospice. At the time of the visit, there were seven residents and two staff members present. LPA conducted staff and resident interviews.

Tour included:

Physical Plant: The facility is one story with seven bedrooms and three bathrooms. The tour of the front entrance, interior and exterior surroundings were observed to be in good repair with no pathway obstruction and facility's water temperature measured at 112.8 degrees Fahrenheit. LPA inspected all of the residents bedrooms and observed them to be clean, and odor free. The inspection also revealed sufficient lighting and mattress pads in residents bedrooms. Furthermore, smoke and carbon monoxide detectors were also inspected and found to be in working order. All cleaning solutions were observed in a locked secure area. The facility does not house firearms and/or ammunition on grounds. Emergency drills are conducted on a quarterly basis. The next drill is scheduled for the first week in August.

Food Services: 7 day non-perishable and 2 day of perishable food supply were observed, and all food was properly stored and available to residents.

Continued on LIC809C...

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 07/23/2023 05:29 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: ANNE'S PLACE IV
FACILITY NUMBER: 374602712

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


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: ANNE'S PLACE IV
FACILITY NUMBER: 374602712
VISIT DATE: 07/23/2023
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Continued from 809...

Staff present have a criminal record clearance on file and are appropriately associated to the facility. LPA review of staff files indicated staff were receiving ongoing training in ADL’s and Dementia Care. LPA review of Resident records indicate that in each file there is a current medical assessment, needs appraisal and a signed, dated admission agreement.

During the medication audit, LPA observed the following deficiencies:

- Medication for all residents was prepared in advance and stored in medication cups up to one day prior to administering to residents. LPA explained to House Manager that medication cannot be transferred from it's original container to another container for storage.

- The facility had PRN medication on hand, such as, Acetaminophen - the facility did not have said medication on MAR list.

Based on observations made by LPA, the facility was cited and deficiencies noted on LIC809D. An exit interview was conducted with House Manager, Dearme Doverte and a copy of this report, LIC809D, LIC811 and appeal rights was provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/23/2023 05:29 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: ANNE'S PLACE IV
FACILITY NUMBER: 374602712

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
(5) Each resident's medication shall be stored in its originally received container. No medication shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the facility did not comply with the section cited above in [7] out of [total 7] (persons) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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House Manager, Derme Doverte, stated he will provide a written statement of understanding of the regulation cited by the POC date of 7/28/2023. House Manager also will train other designated in the proper procedures of storage of medications and provide written statement of training of staff.
Type B
Section Cited
CCR
87465(d)

(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 the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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The facility had PRN medication on hand, such as Acetaminophen - The facility did not have said medication on MAR list, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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House Manager, Dearme Doverte will provide a in-service and re-training to designated staff and medical technicians. Written proof of training will be emailed to the Department by 7/28/23.
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 HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4