374604370-9-28-2023-18-AS-JSRS-CW4VRX-20230928164041

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604370
Report Date: 09/28/2023
Date Signed: 09/28/2023 04:40:51 PM

Document Has Been Signed on 09/28/2023 04:40 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:	KELLY'S OAKHILL VILLA		FACILITY NUMBER:	374604370
ADMINISTRATOR:	MARYLINE SIADTO		FACILITY TYPE:	740
ADDRESS:	1620 OAKHILL DRIVE		TELEPHONE:	(619) 504-5049
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY:	6	CENSUS: 5	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Maryline Siadto, Administrator		TIME COMPLETED:	04:45 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	Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived to the facility to conduct a required annual inspection and was greeted by Administrator, Maryline Siadto. Licensee Garrett Welker arrived shortly. Present at the facility were two (2) staff and five (5) residents. The facility is approved for six (6) non-ambulatory elderly residents; age 60 and above of which one may be bedridden. Hospice waiver is approved for six (6) residents. The facility is a nine (9) bedroom, four (4) bathroom one story house. Each resident has a private room. LPA toured the facility and conducted a general overall inspection of the facility inside and outside. Passageways were observed to be free of obstructions. LPA observed each bedroom to be clean and odor free with the required furnishings. Furniture throughout the facility was in good repair. The facility temperature was 75 degrees. Hot water temperature tested at 110.5 degrees Fahrenheit. Each bathroom contained grab bars for each toilet, bathtub and shower; and non-skid mats or strips in shower or bathtub. LPA observed the kitchen in its entirety. The kitchen appeared clean and odor free. Dishes, cups, pots and pans were observed to be of good quality and quantity. The facility contains a sufficient supply of perishable and non-perishable foods. LPA observed the following and a technical advisory was given for each issue: Knives were stored in the dishwasher as a primary storage space, dishwashing and other cleaning items were stored under the sink in an unlocked cabinet, and one bottle of liquid medication was stored unlocked in the refrigerator. LPA explained to Administrator that these are safety hazards however due to the current census of all residents being bedridden, it is unlikely that residents would have access to these hazards. LPA advised, however, they should be locked and stored appropriately. Continue on LIC 809C

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
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)

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Document Has Been Signed on 09/28/2023 04:40 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: KELLY'S OAKHILL VILLA	FACILITY NUMBER: 374604370
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of records and interview with Administrator, the licensee did not comply with the section cited above in [1count] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Administrator will assist employee with completing the background fingerprint clearance by POC date of Monday October 2, 2023. Administrator will not allow employee to provide care and supervision to residents in care until clearance is obtained. Administrator will not allow employee to return to the facility if clearance is not obtained. Administrator will submit proof of clearance to the Department 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: 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)

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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: KELLY'S OAKHILL VILLA	FACILITY NUMBER: 374604370
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/09/2023
	Plan of Correction
1 2 3 4	Administrator will develop a record keeping system/log of medications administered and submit a copy of the medication log created to the department by POC date. Administrator will also provide additional training to staff on medication management and record keeping. Proof of training will be submitted to the Department by POC.

Deficiency Dismissed

Type B

Section Cited

CCR

87465(h)(5)

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) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/09/2023
	Plan of Correction
1 2 3 4	Administrator will conduct medication management and storage training to staff and will provide proof of training to the Department by POC date.

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: 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)

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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: KELLY'S OAKHILL VILLA	FACILITY NUMBER: 374604370
	VISIT DATE: 09/28/2023

NARRATIVE

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Continued from LIC809....
LPA reviewed first aid kit and it contained the necessary items. LPA also reviewed client files to determine if residents have medical assessments on file. All client files reviewed contain required documents and are current. LPA observed required postings throughout the facility. Drills are conducted quarterly and the last drill was May 5, 2023. Fire extinguishers and smoke alarms were observed to be operable. No firearms or ammunition are stored in the facility. Administrator, Maryline Siadto's certificate expires 10/29/2024.

LPA reviewed facility records to ensure staff have received required training and criminal record clearances. During a review of S3 records it was determined that S3 did not have background clearance on file. LPA was informed by Administrator that S3 lives at the facility and is in the process of obtaining transfer Background Clearance from prior employer to this facility. Per review of S3's personnel file, start date was June 5, 2023. LPA was informed that S3's last worked on Monday, September 25, 2025. Due to S3 working at the facility prior to having their criminal background clearance transferred, the facility will be cited civil penalties at $100 per day worked per employee (S3) with a maximum of $500. Deficiency cited. All other staff are properly associated to the facility. LPA informed Administrator that S3 is not allowed to provide any care and supervision to residents until proof of background clearance is submitted to the department by the plan of correction date.

LPA reviewed medications and the following deficiencies were observed:
- medications were stored in a locked cabinet in the staff office, however medications were observed to be pre-prepared in medication cups. LPA informed Administrator medication is to be always stored and dispensed from its original container unless it is not prepackaged. Medication that is not prepackaged may stored in medication cups for up to 12 hours (Per title 22 87918).

-LPA requested to review medication log records and was informed that the facility maintains a record log of PRN medications only and not other medication that is regularly given because it is in bubble packs that are dated. LPA informed Administrator that per regulations, facility is to maintain a record system similar to that of MAR that indicates, date, time, and name/initials of staff signing off each time medications are dispensed to residents.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
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)

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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: KELLY'S OAKHILL VILLA	FACILITY NUMBER: 374604370
	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	Based on today’s visit, deficiencies were cited per Title 22 and plan of corrections were developed and is noted on the attached LIC 809Ds. An exit interview was conducted and a copy of this report along with the Licensee/Appeal Rights (LIC 9058), LIC811 and LIC421BG were provided to Administrator Maryline Siadto.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
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)

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