Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402418
Report Date: 06/12/2018
Date Signed: 06/12/2018 03:45:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501
FACILITY NAME:LA CADENA MANORFACILITY NUMBER:
336402418
ADMINISTRATOR:DATUIN, MARIAFACILITY TYPE:
735
ADDRESS:5366 LA SIERRA AVENUETELEPHONE:
(951) 687-7059
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:12CENSUS: 12DATE:
06/12/2018
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Alex Frijas and Anelit MayoresTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts Michelle Reed and Shaunte Henry arrived at the home to conduct an Annual/Required visit. Upon arrival, LPAs met with Staff Alex Frijas and Anelit Mayores. Staff Rodolfo "Rudy" Leonardo. Licensee/Administrator Maria Datuin was contacted via telephone by Mr. Frijas. She did not come to the home. A tour of the physical plant was conducted inside and out. At the time of visit, the home was maintained in conformity with State Fire Marshall regulations. All outdoor and indoor passageways were free of obstruction. Sharps and cleaning solutions were NOT inaccessible to clients. Bathrooms were in good repair and sanitary condition. Paper towels were NOT present in bathrooms. There was soap and toilet paper. The home has an operable carbon monoxide detector and smoke detectors. Fire extinguishers are charged and mounted to the wall.
Food was stored in a safe and healthful manner. Supplies of nonperishable foods are maintained on the premises for a minimum of one week and fresh perishables for a minimum of two days. Clients were accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet their needs.
Medications and client files were centrally stored and kept locked and inaccessible to clients. Licensee shall ensure that if staff are going to use a MAR to record the administration of resident medications that it is completed each time the medication is given. Licensee shall also ensure that start dates are placed on the bubble packs of resident medications. Water temperature measured 110 degrees F.
Staff responsible for care and supervision have current first aid training. Administrator Certificate for Maria Datuin expired 5/31/18 and Alejandro Frijas certificate expired on 4/22/18. Mr. Frijas stated that he and Maria sent in their required paperwork but have not received their new certificate. A copy of the certificates shall be sent to Licensing once received. Earthquake drills and fire drills were last conducted 6 months ago. Mr. Frijas stated he will have another one this week. Cash resources, personal property and valuables of clients are not kept by the Licensee. Emergency supplies were not present. Licensee is encouraged to have emergency supplies.

See LIC809D for cited deficiencies per Title 22, Division 6 of the California Code of Regulations cited at this time.

An exit interview was conducted and a copy of this report and appeal rights were given to Ms. Mayores.
SUPERVISOR'S NAME: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (951) 782-4207
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2018
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
CCLD Regional Office, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501

FACILITY NAME: LA CADENA MANOR
FACILITY NUMBER: 336402418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2018
Section Cited
CCR
80087(g)
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BUILDINGS AND GROUNDS-Disinfectants, cleaning solutions, poisons, and other items that could pose a danger to clients shall be inaccessible. Disinfectants, cleaning This regulation was not met as evidenced by:
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Licensee shall ensure that all items that can pose a danger to clients are inaccessible.

The scissors were removed at the time of visit.
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LPA found scissors accessible to clients in Room #2.
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Type A
06/13/2018
Section Cited
CCR
80087(a)(1)
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Buildings and Grounds-The facility shall be kept clean, sanitary and in good repair at all times.

This requirement was not met as evidenced by:
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Licensee shall fix the floor vents in the kitchen and Room #3 and provide proof to Licensing that they have been repaired. Licensee shall also inspect all other bedroom vents and repair them if needed. Certification shall be provided that they were inspected.
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The floor vent in Room #3 and the kitchen are in need of repair. They pose an immediate health and safety concern for clients in care.
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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: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (951) 782-4207
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2018
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501

FACILITY NAME: LA CADENA MANOR
FACILITY NUMBER: 336402418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2018
Section Cited
CCR
80088(a)(1)(A)
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FURNITURE, FIXTURES, EQUIPMENT AND SUPPLIES-A comfortable temperature for clients shall be maintained at all areas.
The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F and a maximum of 85 degrees F. In areas of extreme heat the
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Licensee shall immediately cool the common rooms to at least 30 degrees lower then the outside temperature as Riverside obtains extreme heat temperature. The kitchen and living room shall specifically be addressed. The residents have swamp coolers in their rooms, however this force them to stay in
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maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. This regulation was not met as evidenced by: The temperature in the common areas of the home were 91 degrees F and the temperature outside was 93 degrees F.
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their rooms to keep cool and could violate their personal rights.
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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: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (951) 782-4207
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2018
LIC809 (FAS) - (06/04)
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