374604135-12-16-2024-18-AS-APEZ-DBZTJE-20241216134612

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604135
Report Date: 12/16/2024
Date Signed: 12/16/2024 01:46:25 PM

Document Has Been Signed on 12/16/2024 01:46 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:	SHADOWRIDGE SENIOR LIVING		FACILITY NUMBER:	374604135
ADMINISTRATOR/ DIRECTOR:	MICHELE FUHRMAN		FACILITY TYPE:	740
ADDRESS:	2354 WATSON WAY		TELEPHONE:	(760) 295-3888
CITY:	VISTA	STATE: CA	ZIP CODE:	92081
CAPACITY: 48	TOTAL ENROLLED CHILDREN: 0	CENSUS: 38	DATE:	12/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:10 AM
MET WITH:	Administrator Michele Fuhrman		TIME VISIT/ INSPECTION COMPLETED:	01:50 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), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with administrator, Michele Fuhrman. The LPA informed the Administrator of the purpose for the visit. The inspection included the following:

The facility consists of one building structure with two floors that contain 20 (20) resident bedrooms, a kitchen and dinning area, a living room area, a patio and yard with sufficient seating and space for activities. LPA observed an enclosed outdoor temporary laundry room and water heater that was relocated due to the current construction. Administrator stated that it was set up during construction due to the adjacent building. LPA checked the water temperature is within regulation during the temporary relocation during construction. LPA observed the water temperature to be 103.4. There are no bodies of water located on the property. According to Administrator, no weapons are stored in the facility. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. LPA inspected three resident bedrooms and observed the required furnishing and bathroom items such as grab bars for each toilet, bathtub and shower used by residents. Resident showers have textured non slip floors.

LPA began review of client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete.

Jazmond D Harris	TELEPHONE: (951) 529-2439
Armando Perez	TELEPHONE: (951) 248-2222
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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

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: SHADOWRIDGE SENIOR LIVING	FACILITY NUMBER: 374604135
	VISIT DATE: 12/16/2024

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

LPA began review of employee records- six (6) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 10/13/2026. LPA observed First Aid/CPR records to be missing from 4 out of 6 staff. A deficiency was issued.

LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present in the second floor.

Medications are centrally stored. There is a locked room allocated for medication storage in the first floor. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were recently tested and found to be operational by Vista Fire Department on 12/6/24. LPA observed Fire extinguishers to be current with the last service date of, 03/28/2024. The facility is conducting emergency disaster/fire drills monthly; last done on 11/07/2024.

Based on the information received during this visit today in the areas reviewed, there is one deficiency that is being cited per Title 22, Division 6 of The California Code of Regulations.

This LIC 809 report was reviewed with the facility representative and a copy was provided.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 529-2439
LICENSING EVALUATOR NAME: Armando Perez	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 12/16/2024 01:46 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: SHADOWRIDGE SENIOR LIVING	FACILITY NUMBER: 374604135
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Four out six staff did not have a valid CPR/First Aid certification on file.
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in four out of five persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2024
	Plan of Correction
1 2 3 4	Administrator will be updating LPA within 24 hours the plan on the training for the required staff. The course must be completed within 10 days. Administrator will provide proof of valid CPR/First Aid certification by email.

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.

Jazmond D Harris	TELEPHONE: (951) 529-2439
Armando Perez	TELEPHONE: (951) 248-2222
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3