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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602712
Report Date: 07/25/2024
Date Signed: 07/25/2024 01:46:31 PM


Document Has Been Signed on 07/25/2024 01:46 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: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: 9DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Dearme Doverte, Administrator TIME COMPLETED:
01:55 PM
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On 7/25/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility for the purpose of conducting a 1 year required visit/annual inspection. LPA George met with Dearme Doverte, Administrator and informed of the purpose of today's visit. The facility is licensed to serve 10 non ambulatory residents, ages 60 and above, and approved to have up to 10 bedridden residents. The facility has an approved hospice waiver for (6). There are currently (2) residents receiving hospice services. Below is a summary of what was observed during today’s inspection:

Infection Control: LPA George observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. The facility was observed to have an adequate supply of Personal Protective Equipment (PPE) supplies.

Physical Plant: LPA toured the interior and exterior of the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. The facility was observed to have the required furniture and linen to be present and in good condition in resident bedrooms. The exits are not obstructed and that there is plenty of space for activities. The facility was observed to have operable flashlights. There are no pools or bodies of water on the premises.

Records Review-Staff Records: LPA George confirmed that there is an Administrator present with a valid Administrator certificate. LPA George confirmed staff have criminal record clearance and were associated to the facility and have training to perform their required duties. All staff present at have current CPR/First Aid Certification. Resident Records: A review of all (4) current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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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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: ANNE'S PLACE IV
FACILITY NUMBER: 374602712
VISIT DATE: 07/25/2024
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Food Services: The kitchen and dining area to be maintained in a clean and healthful manner. Sufficient dishware and silverware were present for resident’s use. LPA George observed the facility to have the required amount of 7 day supply non-perishable and a two supply perishable food items.

Medication: Resident medication was observed to be locked in the cabinet next to the refrigerator and inaccessible to residents in care. The facility is utilizing an electronic program Alcomy, in addition to using a hard copy of the Medical Authorization Record (MAR).

Emergency Disaster Preparedness: The facility has an Emergency Disaster Plan on file and conducts regular disaster drills on a quarterly basis. The last drill was conducted on 07/01/24. The dual smoke and carbon monoxide detectors were tested and were found to be operable. The facility has (3) fully charged fire extinguishers. There are no known guns or ammunition on the premises. After the hot water heater was adjusted the hot water was tested and was found to be within regulatory limits. The facility has emergency food and water supply. The sharps and hazardous chemicals were observed to be locked and inaccessible to residents in care.

The facility will provide the following documents for the facility file at the Regional Office:
-LIC 500 Personnel Report
-Updated facility sketch (office, and caregiver room) small garage
-Liability insurance

Based on today's inspection there were no deficiencies cited.

An exit interview was conducted and a copy of this report, were provided to Dearme Doverte, Administrator.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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