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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
374603665
Report Date:
07/26/2023
Date Signed:
07/26/2023 03:28:27 PM
Document Has Been Signed on
07/26/2023 03:28 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:
DEVON PLACE HOME CARE
FACILITY NUMBER:
374603665
ADMINISTRATOR:
MARK LOO
FACILITY TYPE:
740
ADDRESS:
1814 DEVON PLACE
TELEPHONE:
(760) 941-1818
CITY:
VISTA
STATE:
CA
ZIP CODE:
92084
CAPACITY:
6
CENSUS:
5
DATE:
07/26/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:01 AM
MET WITH:
Rina Canomizado
TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cheryl Goodrich conducted an unannounced annual visit. LPA met with the Caregiver Nestor Blay at the front door and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility follows California Code of Regulations, Title 22, Division 6. Facility is approved for five (5) ambulatory and non-ambulatory residents.
Physical Plant:
front entrance, interior and surrounding exterior were clean and in good repair with no pathway obstruction; doorway alarms were in working order; residents' main restroom water temperature read at 119.1 degrees; there were no bodies of water on premises; there was sufficient lighting and mattress pads in all of the residents' bedrooms; fire alarm and smoke carbon monoxide detectors were in working order. Facility does not house firearms and/or ammunition on grounds.
Food Services
: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available to residents. No emergency food supply was observed.
Medication/Facility Records:
Medications were observed to be labeled and in a locked place that is inaccessible to residents. All staff subject to a criminal record review obtained fingerprint clearance and/or an exemption.
(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:
07/26/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/26/2023
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
12
Document Has Been Signed on
07/26/2023 03:28 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:
DEVON PLACE HOME CARE
FACILITY NUMBER:
374603665
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/26/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation of facility records and staff's admission , the licensee did not comply with the section cited above in 2 out 2 staff members, and the administrator.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
07/28/2023
Plan of Correction
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Administrator states that he will have the staff and his CPR/ First Aid training completed by the due date listed above. Administrator states he will make sure CPR/First Aid training is scheduled 1-2 months prior to the expiration date.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations knives were accessible to the residents, the licensee did not comply with the section cited above in 6 out 6 counts, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
07/28/2023
Plan of Correction
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Administrator states he will secure the knives and put them in a locked cabinet temporarily and purchase a locked cabinet for permanent location.
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:
07/26/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/26/2023
LIC809
(FAS) - (06/04)
Page:
2
of
12
Document Has Been Signed on
07/26/2023 03:28 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:
DEVON PLACE HOME CARE
FACILITY NUMBER:
374603665
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/26/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of facility records residents with dementia have no medical assessment., the licensee did not comply with the section cited above in 2 out of 5 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/11/2023
Plan of Correction
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Administrator states that he will work on getting resident assessments for current conditions for resident and provide medical assessments.
Type B
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of interactions between R4 and S2 while at the facility and based on interview with R1, the licensee did not comply with the section cited above in 2 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/04/2023
Plan of Correction
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Administrator states that he will conduct an in-service regarding residents rights and communication.
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:
07/26/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/26/2023
LIC809
(FAS) - (06/04)
Page:
3
of
12
Document Has Been Signed on
07/26/2023 03:28 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:
DEVON PLACE HOME CARE
FACILITY NUMBER:
374603665
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/26/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and review of medication records, the licensee did not comply with the section cited above in 5 out of 5 for all residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/04/2023
Plan of Correction
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Administrator states that he will have the medication technician from hospice come to do a training. Administrator state he will continue to check the MAR's daily to make sure the records are kept in order and complete.
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
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Based on record review of the fire drills, the licensee did not comply with the section cited above in 2 out of 2 fire drills which were not completed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/04/2023
Plan of Correction
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Adminstrator states he will conduct an in-service to conduct a fire drill with staff.
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:
07/26/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/26/2023
LIC809
(FAS) - (06/04)
Page:
4
of
12
Document Has Been Signed on
07/26/2023 03:28 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:
DEVON PLACE HOME CARE
FACILITY NUMBER:
374603665
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/26/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review of all resident files, the licensee did not comply with the section cited above in 5 out of 5 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/11/2023
Plan of Correction
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Administrator states that he will have the medical assessments completed for all residents and continue to maintain physician reports on an annual basis by scheduling in advance.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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:
07/26/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/26/2023
LIC809
(FAS) - (06/04)
Page:
5
of
12
Document Has Been Signed on
07/26/2023 03:28 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:
DEVON PLACE HOME CARE
FACILITY NUMBER:
374603665
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/26/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(f)(2)(D)
Other Provisions
(f) A facility shall have both of the following in place: (2) A set of keys available to facility staff on each shift for use during an evacuation that provides access to all of the following: (D) All facility cabinets and cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation of the emergency food supply, there was none presen, the licensee did not comply with the section cited above in 1 out of 1, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
07/28/2023
Plan of Correction
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2
3
4
The Administrator states he will provide emergency food supplies for the residents and staff.
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:
07/26/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/26/2023
LIC809
(FAS) - (06/04)
Page:
11
of
12
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:
DEVON PLACE HOME CARE
FACILITY NUMBER:
374603665
VISIT DATE:
07/26/2023
NARRATIVE
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(Continued from LIC809)
Licensee has completed a written admission agreement and needs and service plan with each resident. Waivers are in place and meet said terms. Licensee handles no resident cash resources. Administrator Certificate is current and will expire on November 2024
Items Discussed:
Knives were left in kitchen drawer accessible to residents. Both staff are not CPR/First Aid certified. The staff is not documenting the date or time PRN medications are administered to the residents which is evidenced by review of resident record. The staff (S1) is communicating with the physician’s regarding PRN medications however does not document the contact with the physicians responsible for prescribing the medication. The staff are not providing activities to the residents. The Administrator has not conducted any fire drills since 2022. The Administrator does not have a resident roster for the facility. LPA Goodrich was informed by residents R1 that S2 ignores her requests for items and assistance and only “does it when he feels like it”. Resident (R1) states she is not treated well by that staff member and they got into an argument prior to my arrival. Staff (S2) was observed fixing coffee for R4, and R4 continued to ask to ask S2 for coffee, but none was provided until much later.
Summary
: Based on today's visit, deficiencies were observed, and the facility has been cited. An exit interview was conducted with staff Nestor Blay and a copy of this report was printed Signature below confirms receipt of these rights and appeal rights given.
SUPERVISOR'S NAME:
Jazmond D Harris
TELEPHONE:
(951) 248-0318
LICENSING EVALUATOR NAME:
Cheryl Goodrich
TELEPHONE:
951-248-0308
LICENSING EVALUATOR SIGNATURE:
DATE:
07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/26/2023
LIC809
(FAS) - (06/04)
Page:
12
of
12