374603478-7-15-2023-18-AS-JSRS-CTRTGZ-20230715144359

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603478
Report Date: 07/15/2023
Date Signed: 07/15/2023 02:44:06 PM

Document Has Been Signed on 07/15/2023 02:44 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:	CHAMPINE MANOR		FACILITY NUMBER:	374603478
ADMINISTRATOR:	SRBIJANKA ZIVKU		FACILITY TYPE:	740
ADDRESS:	1725 TOBACCO ROAD		TELEPHONE:	(760) 747-3878
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	6	CENSUS:	DATE:	07/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:28 AM
MET WITH:	Administrator Virna Liza Austria		TIME COMPLETED:	02:45 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	On July 15, 2023, Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived unannounced at the facility to conduct an annual inspection. LPA was greeted and granted entry by Caregiver, Agus Sinoman who was informed of the purpose of visit. Administrator, Virna Liza Austria arrived at the facility shortly after. At the time of visit there were 2 staff and 6 residents present. Two staff and three residents was interviewed. LPA toured the facility inside and out. The balconies and outside facility were observed to be clean and furniture in good condition. The outside area is free from obstructions and no bodies of water were observed. The facility is one story and has six bedrooms and three bathrooms. LPA observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility. LPA observed bathrooms to be clean with grab bars and hot water was measured at 118.7 degrees Fahrenheit. The laundry room was observed to be clean, equipped with washing machine and dryer. LPA observed laundry solutions are adequately secured in a locked cabinet. LPA observed kitchen to be clean and food stored in a safe and healthful manner.There are seven days non-perishable and two days of perishable food supply present. LPA observed knives stored in a locked cabinet and cleaning solutions are adequately stored under the kitchen sink. LPA observed the dining and living area to be clean and furniture in good condition. Temperature was 77 degrees Fahrenheit. LPA observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CHAMPINE MANOR	FACILITY NUMBER: 374603478
	VISIT DATE: 07/15/2023

NARRATIVE

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Continued From LIC809
Carbon monoxide & smoke detector were tested and functioning properly. Emergency drills are conducted quarterly. All required postings, were posted near the entryway and throughout the facility.

LPA observed medications were labeled and stored inside of a locked medication cabinet. The first aid kit was complete. During inspection of medications, LPA observed the following deficiency:

- Medications were not being dispensed as required - LPA observed medication that was already pre-prepared in a medication tray.

LPA inspected five staff and three client records. All staff have a criminal record clearance in file and are confirmed as being associated with the facility. Staff files had the required documentation including First Aid Certifications and training documents. The administrator submitted renewal for license certificate on March 16, 2023 and is currently awaiting a new certificate.

Based on observations made by LPA, the facility was cited and deficiency noted on LIC809D. An exit interview was conducted with the Administrator Virna Liza Austria and a copy of this report, LIC809D, and appeal rights was provided.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/15/2023 02:44 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: CHAMPINE MANOR	FACILITY NUMBER: 374603478
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(k)(6)

The following requireents shall apply to medications which are centrally stored. No medications shall be transferred between containers. This requirement is not met as evidenced by: Medication was observed to be pre-prepared in pill trays. Medication is to be dispensed directly from its original containers to residents.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [6] out of [6] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2023
	Plan of Correction
1 2 3 4	Administrator agreed to conduct in-service training regarding client's medication and storing them in original containers. Administrator agreed to submit staff roster and training material to LPA by POC date.

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: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2023

LIC809 (FAS) - (06/04)

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