374603585-11-7-2024-18-AS-SMAZ-DASUWH-20241107145647

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603585
Report Date: 11/07/2024
Date Signed: 11/07/2024 02:57:03 PM

Document Has Been Signed on 11/07/2024 02:57 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:	ALVIN'S HOMECARE		FACILITY NUMBER:	374603585
ADMINISTRATOR/ DIRECTOR:	JOHN BULAORO		FACILITY TYPE:	740
ADDRESS:	724 DRIFTWOOD LANE		TELEPHONE:	(760) 990-4694
CITY:	FALLBROOK	STATE: CA	ZIP CODE:	92028
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	11/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:40 PM
MET WITH:	Ailyn Bulaoro - Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:05 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) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with caregiver Josephine Bulaoro who was informed of the purpose of today's visit. Administrator Ailyn Bulaoro arrived during LPA's visit. At the time of the visit there was four (4) staff and five (5) residents present. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. LPA observed outdoor furniture and shaded area for clients. Detergents, cleaning solutions, and sharp and dangerous objects were observed to be locked and inaccessible to residents in the garage. The smoke detector and carbon monoxide was operational. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA reviewed staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training. Three (3) resident files were reviewed. Record review revealed Resident One (R1), Resident Two (R2), and Resident Three (R3) do not have an updated appraisal dated within the last 12 months. A deficiency will be issued under Title 22 Regulation 87467(a)(3) along with a plan of correction. Record review revealed R1 who has diagnoses of Dementia does not have an updated LIC 602 Physician's Report. A deficiency will be issued under Title 22 Regulation 87705(c)(5) along with a plan of correction. The listed administrator Ailyn Bulaoro possesses a current administrator's certificate that expires in 2025. Resident medication was centrally stored and locked in a hallway closet. LPA observed medication for residents in a daily pill box. Interview with staff revealed medication is being transferred from the original medication container to the daily pill boxes. A deficiency will be issued under Title 22 Regulation 87465(h)(5) along with a plan of correction

Tricia Danielson	TELEPHONE: (951) 202-5067
Sara Martinez	TELEPHONE: (951) 605-0913
	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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 11/07/2024 02:57 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: ALVIN'S HOMECARE	FACILITY NUMBER: 374603585
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in having pre-packed daily pill boxes filled with residents' medication which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Licensee will immediately stop using pill boxes for the residents' medication. In-service training on how to administer medication will be conducted with staff and proof of training will be submitted to LPA by the plan of correction date 11/22/2024

Section Cited

Care of Persons with Dementia: (c) Licensees...shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in having an annual medical assessment conducted for Resident One (R1) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2024
	Plan of Correction
1 2 3 4	Licensee will ensure all of the residents with dementia shall have an annual medical assessment conducted and will submit proof to LPA by the plan of correction date 12/06/2024

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Tricia Danielson	TELEPHONE: (951) 202-5067
Sara Martinez	TELEPHONE: (951) 605-0913
	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/07/2024 02:57 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: ALVIN'S HOMECARE	FACILITY NUMBER: 374603585
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Resident Participation in Decisionmaking

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by:
	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 three (3) out of three (3) residents who has not had an updated appraisal within the past 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2024
	Plan of Correction
1 2 3 4	Licensee will conduct resident appraisals for five out of five residents. Licensee will review regulation and send statement of understanding of the regulation cited above to LPA by the plan of correction date 12/06/2024

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Tricia Danielson	TELEPHONE: (951) 202-5067
Sara Martinez	TELEPHONE: (951) 605-0913
	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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: ALVIN'S HOMECARE	FACILITY NUMBER: 374603585
	VISIT DATE: 11/07/2024

NARRATIVE

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LPA reviewed the facility's emergency and disaster plan and infection control plan. Facility conducts quarterly fire drills with the last fire drill being conducted in October 2024. All facility exits were clear from obstructions. LPA observed emergency supplies, multiple charged fire extinguishers, and first aid kit with all required items.

An exit interview was conducted where a copy of this report, deficiency page LIC 809-D, confidential names LIC811, and appeal rights was provided to Administrator Bulaoro.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

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