374602951-3-20-2024-18-AS-JSRS-D3JSFR-20240320135045

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602951
Report Date: 03/20/2024
Date Signed: 03/20/2024 01:51:10 PM

Document Has Been Signed on 03/20/2024 01:51 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:	PACIFIC SUNSET - EUREKA SPRINGS		FACILITY NUMBER:	374602951
ADMINISTRATOR:	MUNAR, VICTORINO		FACILITY TYPE:	740
ADDRESS:	3131 CRANE AVENUE		TELEPHONE:	(760) 294-6997
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY:	6	CENSUS: 2	DATE:	03/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Amelia Perlow, 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, Amelia Perlow and explained the purpose of the visit. A tour of the facility was conducted inside and out. Present at the facility were two clients and one additional staff was available. The facility is a four (4) bedroom four (4) bathroom one story home. During the tour the following was observed: Clients 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 to clients. Hot water was tested at 118.5 degrees Fahrenheit. 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. The following deficiency was observed: The Administrator could not recall nor have record of the last emergency drill conducted. LPA advised Administrator drills are to be conducted quarterly. Deficiency cited.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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 03/20/2024 01:51 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: PACIFIC SUNSET - EUREKA SPRINGS	FACILITY NUMBER: 374602951
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2024

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
1 2 3 4	Based on interview and record review, the facility staff CPR/1st Aid certification expired on 6/7/2023 and has not been renewed yet. The facility did not comply with the section cited above in [3] out of [3] persons which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/30/2024
	Plan of Correction
1 2 3 4	Licensee will ensure staff have renewed their CPR/1st Aid Certification and will provide proof of renewal to the Department by POC date.

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the facility did not maintain a record of medication dosages for the Department to review. The licensee did not comply with the section cited above in [2] out of [2] persons which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/30/2024
	Plan of Correction
1 2 3 4	The Licensee will update their record of medication dosage (MAR) and provide proof to the Department that it has been updated by POC date. The Licensee will also provide refresher training to staff of record-keeping of medication dosage by POC date.

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) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/20/2024 01:51 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: PACIFIC SUNSET - EUREKA SPRINGS	FACILITY NUMBER: 374602951
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on interview and record review, the facility did not have an updated record of drills conducted with staff that include the type of drill, date of drill and staff names who participated in the drill. The facility did not comply with the section cited above in [3] out of [3] persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/30/2024
	Plan of Correction
1 2 3 4	Facility will conduct an emergency drill quarterly and on a regular basis. Facility will keep documentation of the drills that will include the type of emergency covered by the drill, and the names of staff participating in the drill. Administrator will provide proof to the Department of the most recent emergency drill conducted by the POC date.

Type B

Section Cited

CCR

87307(2)(C)

...No bedroom of a resident shall be used as a passageway to another room, bath, or toilet. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, LPA was informed a resident-occupied masterbedroom has a bathroom that is frequently used by other residents. The facility did not comply with the section cited above in [1] out of [1] persons which poses personal rights risk to persons in care.
	POC Due Date: 03/30/2024
	Plan of Correction
1 2 3 4	Facility will immediately cease from allowing other residents to use the bathroom in the resident-occupied masterbedroom. Administrator will ensure another bathroom is used instead. Administrator will review the regulation with staff and provide a letter of understanding to the Department by the POC date.

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) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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: PACIFIC SUNSET - EUREKA SPRINGS	FACILITY NUMBER: 374602951
	VISIT DATE: 03/20/2024

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Record Review and Client/Staff Files: LPA reviewed current staff and all staff have has Criminal Background Clearance and trainings are current, however the following deficiency was observed:
-The facility staff did not have current CPR/First Aid certification. Certification for all staff expired on 6/7/2023. Deficiency cited.

Client records were reviewed and contained required documents that included Admission Agreement, Pre-Appraisal, current Physician's Report.

Medication Review: LPA reviewed medication and medications appear to be dispensed according to physician's orders, however the following deficiency was observed:
- The facility did not have an updated medication record keeping system of medication dosages given to residents. Administrator stated they are in the process of updating the system. Deficiency cited.

An exit interview was conducted and a copy of this report along with LIC 809D, LIC811, and Appeals Rights was provided to Administrator, Amelia Perlow.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC809 (FAS) - (06/04)

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