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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376401726
Report Date: 05/08/2023
Date Signed: 05/08/2023 03:41:44 PM

Document Has Been Signed on 05/08/2023 03:41 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MICHAELLE HOUSEFACILITY NUMBER:
376401726
ADMINISTRATOR:PAUL KEARSCHNERFACILITY TYPE:
736
ADDRESS:687 RIVIERA COURTTELEPHONE:
(760) 758-9165
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 12CENSUS: 11DATE:
05/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:House Manager, Cristal KacerikTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 5/8/2023 at 12:36 p.m. LPA was granted entry and met with , House Manager Cristal Kacirek who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (6) clients present.

The facility is a two story home with (6) bedrooms and (4) bathrooms and pool. No firearms are being kept at the facility. The clients served are adults between the ages of 18 and up. The facility is a residential care facility for the chronically ill. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that staff have received infection control training.



Physical Plant: LPA observed the client bedrooms. Physical plant, carpet on stairs, t.v room, upstairs loft, and resident restroom were not in clean condition. Carpets multiple visible stains, LPA was informed that the staff planned to clean the carpet by the end of the week and will send LPA photos. The outdoor area was observed to be free of hazards. Pool is surrounded by a locked gate. LPA observed outdoor furniture and shaded area for residents. Laundry equipment was observed to be in working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at 106.6F.

Food Service: LPA observed 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.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MICHAELLE HOUSE
FACILITY NUMBER: 376401726
VISIT DATE: 05/08/2023
NARRATIVE
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Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and training along with CPR/First Aid Certification. LPA was informed that the administrator did not have the required 20-hours of TB and HIV/AIDS training on file. It was also revealed that all staff do not have the 20-hour training requirement. Deficiency was documented for this along with plan of correction. The listed administrator has a current administrator's certificate. Two (2) client files were reviewed, LPA found that clients did not have copies of their most recent TB test on file at the facility. Deficiency was cited for this along with plan of correction.

Health Related Services/ Incidental Medical Services: All client medication was locked in a medication room. LPA reviewed client medications and found all medication listed on MARS and all required labeling was found to be in place. LPA observed client medication was punched for the 9th, when it is currently the 8th. Staff stated that medication for the 9th was punched and showed LPA medication cup where medication was prepped for the next day. LPA communicated to staff that this practice is not incompliance with Title 22 regulations. The deficiency was cited and plan of correction was documented.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The last facility fire drill meet the department requirements. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report along with deficiency pages and appeal rights were reviewed provided to House Manager, Cristal Kacirek.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/08/2023 03:41 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/08/2023 at 03:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MICHAELLE HOUSE
FACILITY NUMBER: 376401726

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87915(a)(4)
Storage of Medications
(a) The following requirements shall apply to medications which are centrally stored: (4) Each resident's medication shall be stored in its originally received container.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with (1) resident;s medication that was found to be punched for the following day (9th) whehn current date was the (8th). LAP observed the medication in a labeled cup in the medication room. STaff stated this was done due to the resident going to a doctor's appointment the following moring. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2023
Plan of Correction
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The house manager agreed to send the LPA a written statement on how they plan to handel resident appointments and medications, so that the facility may stay in complaince with title 22. This is due to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/08/2023 03:41 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/08/2023 at 03:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MICHAELLE HOUSE
FACILITY NUMBER: 376401726

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87865(g)(7)
Personnel Requirements
(g) All direct care facility staff shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the resident population served and, to the job assigned: (7) All direct care staff shall have 20 hours of on-the-job training on AIDS-related conditions and the early recognition and prevention of tuberculosis, within three months after employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with the administrator not having a total of 20 hours of tb and HOV/AIDS training on file during the time of the visit/. The house manager revealed that not all staff have this in their file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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The house manager agreed to send in a written statement asserting that all staff have received the required 20-hour trainin gfor TB and HIV/AIDS by the POC due date. Statement shall include what staff have received the training.
Type B
Section Cited
CCR
87870(b)(9)
Resident Records
(b) Each record shall contain information including, but not limited to, the following; (9) Copy of tests for tuberculosis:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with (2) resident that did not have their most current TB test on file. LPA was unable to confirm TB test for (1) of these sresident during the vsiit. (1) resident confirmed through interview of recent TB test conducted. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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The house manager agreed to send the LPA a copy of the most recent TB for both resident by the POC due 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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023


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