374603157-9-28-2023-18-AS-CGOH-CW4PRZ-20230928113334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603157
Report Date: 09/28/2023
Date Signed: 09/28/2023 11:33:44 AM

Document Has Been Signed on 09/28/2023 11:33 AM - 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:	OUR FAMILY CARE HOME, LLC		FACILITY NUMBER:	374603157
ADMINISTRATOR:	CODAY, BRIAN		FACILITY TYPE:	740
ADDRESS:	810 CENTENNIAL DRIVE		TELEPHONE:	(760) 630-2762
CITY:	VISTA	STATE: CA	ZIP CODE:	92081
CAPACITY:	6	CENSUS: 5	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:43 AM
MET WITH:	Administrator, Brian Cody		TIME COMPLETED:	11:33 AM

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) Cheryl Goodrich arrived at 9:43 AM. to conduct an unannounced annual visit. LPA met the Administrator Brian Coday at the front door and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for six (6) non-ambulatory residents with 5 non-ambulatory residents in care. The facility has hospice waiver. Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies. Physical Plant and Environmental Safety: The facility temperature read at 74 degrees. The facility consists of 3 resident bedrooms, and 2 bathrooms, living room, kitchen, 1 staff bedroom and backyard. The bedrooms are furnished with tv, lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 107.6 degrees within regulation requirements. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the kitchen and inaccessible to the resident. The facility and has a current fire clearance, smoke and carbon monoxide detectors and fire extinguishers and are in working order. Personnel Records-Training: The staff records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings. Client Records-Incident Reports: The facility has pre-placement appraisal, identification and emergency information, physician’s report, resident appraisal, hospice documentation, client rights, and admissions agreement. (Continued on LIC809-C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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

Document Has Been Signed on 09/28/2023 11:33 AM - 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: OUR FAMILY CARE HOME, LLC	FACILITY NUMBER: 374603157
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 5 residents do not have physician's reports which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	The Administrator Brian Coday will send a text message with the first and last page of the physicians report. The Administrator will add this event to his monthly review to continue in compliance.

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	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

Page: 2 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: OUR FAMILY CARE HOME, LLC	FACILITY NUMBER: 374603157
	VISIT DATE: 09/28/2023

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 LIC809)

Client Rights-Information: The facility has client rights information posted in the facility.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available.
Health- Related Services: The facility has a medication logbook, and the facility documented the resident’s medication and in compliance with physician’s orders and regulations.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 08/01/23 at 9:30 AM. The facility has emergency supply of food and water.
Items Discussed: Resident R2 and R5 do not have current physicians reports.
Summary: Based on today visit, a deficiency is being cited. An exit interview was conducted and a copy of this report was provided to Administrator Brian Coday. LPA provided a copy of his Appeal Rights and his signature on this form acknowledges receipt of these rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3