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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800173
Report Date: 01/25/2024
Date Signed: 01/25/2024 01:40:24 PM

Document Has Been Signed on 01/25/2024 01:40 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MEGGINSON PLACE IIFACILITY NUMBER:
331800173
ADMINISTRATOR:RACELIS, JANETTEFACILITY TYPE:
740
ADDRESS:11330 LOMBARDY LANETELEPHONE:
(951) 363-8767
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 5DATE:
01/25/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Janette Racelis, Licensee/AdministratorTIME COMPLETED:
01:55 PM
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On today's date 01/25/14, Licensing Program Analyst (LPA) Javina George conducted an unannounced Health and Safety check at the facility. LPA was greeted and granted entry by Licensee Janette Racelis, and explained the purpose of the visit. At the time of LPAs visit there were two (2) staff and five (5) resident's present. Both staff were observed to have obtained criminal record clearance and were associated to the facility. There were (2) resident's sleeping, (1) resident eating and (2) resident's watching a television program. The resident's observed in the common area and at the dining room table were were observed to be dressed and well groomed.

The facility has an approved hospice waiver for four (4) residents. The facility currently has three (3) residents that are under hospice care. All resident's on hospice have a DNR as indicated on their Physician's Orders for Life Sustaining Treatment (POLST). LPA did not observe any additional advanced health care directives for the residents under hospice care.

LPA conducted a tour of the interior and exterior of the facility. The facility has five (5) residents bedrooms and (2) staff bedrooms and 4 bathrooms. There is currently one vacant resident bedroom. Upon arrival to the facility LPA observed for the driveway where it meets at the sidewalk to be uneven. LPA estimates the gap to be about a 4-5" gap between the sidewalk and end of the driveway. The pavement is uneven on the right side of the facility if you are standing across the street, looking at the facility. LPA observed for there to be an orange cone present, highlighting the uneven pavement. LPA inquired with the Licensee Mrs. Racelis if the shift in foundation is something that has happened over time.

Mrs. Racelis stated that the shift/uneven pavement have been a result of the recent earthquake that occurred a couple of weeks ago. Mrs. Racelis stated that she has been in communication with the property owner, who stated the pavement will be repaired. The is a current appointment with a foundation company is scheduled for 1/30/24 at 9am to estimate the cost of repair. The Licensee will send proof of estimate,
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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 2
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: MEGGINSON PLACE II
FACILITY NUMBER: 331800173
VISIT DATE: 01/25/2024
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confirming that the the facility is working to repair the uneven pavement. At this time a citation is not being issued as the shift in foundation is out of the control of the facility staff. Due to the Licensee taking the necessary steps to repair the pavement. Once the estimate is provided and consultation with the property owner is completed, the Licensee will provide an update to the department in regards to the expected plan of action to repair the driveway.

LPA observed for the facility to be utilizing video surveillance. LPA observed for there to be one (1) camera in the dining room, and two (2) cameras inside of the living room, one (1) camera in the hallway as well as a doorbell camera and in the backyard throughout the outside perimeter of the facility. There were no cameras observed in the resident bedrooms. Per the Licensee Mrs .Racelis the cameras were installed about three years ago, and are used to provide increased supervision, especially if a resident begins to wander. LPA informed Licensee that the facility was required to update the facility sketch indicating where the cameras are throughout the facility, an addendum to the facility's plan of operation, as well as a consent to video surveillance for the residents. If the Licensee does not submit the required updates to the department by 5pm on 2/08/24, as agreed by the Licensee the facility will be cited.

LPA observed for the facility to be clean, odor and clutter free. The facility was observed to have at minimum of a 30 day supply of Personal Protective Equipment (PPE). The PPE consisted of gloves, gowns, masks both surgical and N95 respirator's, and face shields. LPA observed for the facility to have paper supplies (paper towels, and napkins). The facility has EPA approved cleaners (bleach, Pine Sol, Lysol, disinfectant wipes and spray). The facility has an abundance of hygiene supplies available for residents in care to use. The resident's medications were observed to be locked and inaccessible to the resident's in care.

The facility was observed to have the required docs such as personal rights, Emergency disaster plan, facility License, LTCO poster and department complaint poster (PUB 475). The facility's food supply was observed to meet the requirements of a 2 day supply of perishable and a 7 day supply of nonperishable food items.

LPA conducted follow up in regards to a recent discussion that was held on 1/14/24, between the department and the Licensee Janette Racelis, where guidance was provided. LPA inquired about the follow up taken after the discussion and the Licensee did not follow the guidance given. A technical violation is being issued.

An exit interview was conducted, and a copy of this report, LIC9102, and LIC 811 were discussed and provided to Licensee Janette Racelis.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
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