374602817-9-22-2023-18-AS-JSRS-CVWVGQ-20230922162555

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602817
Report Date: 09/22/2023
Date Signed: 09/22/2023 04:26:04 PM

Document Has Been Signed on 09/22/2023 04:26 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:	EUREKA SPRINGS HOME		FACILITY NUMBER:	374602817
ADMINISTRATOR:	JIMENEZ, JEFFREY		FACILITY TYPE:	735
ADDRESS:	556 EUREKA DRIVE		TELEPHONE:	(760) 294-5602
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY: 6		CENSUS: 5	DATE:	09/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Mariles Roy, Care Provider		TIME COMPLETED:	04:30 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 conducted an unannounced required annual inspection. LPA met with Mariles Roy, Caregiver 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 six (6) Developmentally Disabled Adults; ages 18 and above of which two (2) may be non-ambulatory in approved rooms only. At the time of the visit, there were two staff members present and no clients available. LPA was informed that all clients were attending day program. LPA was able to speak with Administrator Jeffrey Jimenez by telephone throughout the inspection.

Tour included:

Physical Plant: The facility is one story with four (4) bedrooms and two (2) 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 108.4 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 monthly basis. The last drill was conducted on 9/1/23.

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...

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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 3

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: EUREKA SPRINGS HOME	FACILITY NUMBER: 374602817
	VISIT DATE: 09/22/2023

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
26
27
28
29
30
31
32

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 and are CPR/1st aid certified. LPA review of client records indicate that in each file there are current IPP reports, physician reports, pre- appraisal and signed, dated admission agreements. P&I log was audited and balances were verified as accurate. P&I funds are kept separately from facility funds.

During the medication audit, LPA observed the following deficiency:

- Medication for all five residents was prepared in advance and stored in medication cups prior to administering to residents. LPA explained to Administrator by telephone and to staff present that medication cannot be transferred from it's original container to another container for storage.

Based on observations made by LPA, the facility was cited and a deficiency was noted on LIC809D. An exit interview was conducted with Care Provider, Mariles Roy, who was authorized by the Administrator to sign on his behalf. A copy of this report, LIC809D, LIC811 and appeal rights was provided to Care Provider.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/22/2023 04:26 PM - It Cannot Be Edited

Created By: Jacqueline Shaw Ross On 09/22/2023 at 03:48 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: EUREKA SPRINGS HOME	FACILITY NUMBER: 374602817
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

80075(n)(5)

Medications shall be stored in its original containers. This requirement is not met as evidenced by: Medication was prepared in advance and stored in medication cups.
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in [5] out of [5] [(objects) [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Administrator will immediately destroy current medication that was not stored in its original container and will administer medication from its origninal container moving forward. Administrator provide additional training in medication storage and management to all staff who are authorized to manage and administer medications. Adminstrator will provide proof of training completed.

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

LICENSING EVALUATOR NAME:

Jacqueline Shaw Ross

LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3