<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880563
Report Date: 10/10/2024
Date Signed: 10/10/2024 01:34:57 PM

Document Has Been Signed on 10/10/2024 01:34 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:RWINS ELDERLY'S HAVENFACILITY NUMBER:
331880563
ADMINISTRATOR/
DIRECTOR:		PERGANTIS, ALICIAFACILITY TYPE:
740
ADDRESS:4960 RED BLUFF RDTELEPHONE:
(714) 398-9566
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 6CENSUS: 6DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:09 AM
MET WITH:Alicia Pergantis, AdministratorTIME 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), Stephanie Martinez, conducted a required annual inspection to the facility. The LPA was allowed entrance into the facility and met with Administrator, Alicia Pergantis. The LPA informed the Administrator of the purpose for the visit. The inspection included the following:

Physical Plant: The facility consists of four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, storage areas/closets, a kitchen and dinning area, a living room space, a laundry room, a garage, and a patio and yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator Pergantis, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats or strips present. The carbon monoxide and smoke detector were tested by staff and observed to be in operating condition.

Food Service: There is a minimum of 2 days supply of perishable foods and 1 week's supply of non-perishable foods available. A variety of food was available and stored in a safe and healthful manner. Sufficient dinning supplies were available for residents in care.

Record Review: There is a disaster and mass casualty plan in place. The facility has a copy of the Plan of Operation available. The Administrator reviewed the facility's profile and reported all information is accurate and up to date. All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Dementia care training, postural support training, restricted healthcare training and hospice training was not observed on file for Staff Two (S2) or Three (S3). S2 was interviewed & reported they have had dementia training (3 hours) several months ago. S2 could not recall when other training was completed. S3 was interviewed & could not recall when the training was completed. A citation
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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: RWINS ELDERLY'S HAVEN
FACILITY NUMBER: 331880563
VISIT DATE: 10/10/2024
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
will issued. The facility was not operating beyond the conditions specified on the license. The facility currently has an approved Hospice Waiver for five (5) residents and there are currently three (3) residents in care receiving hospice services. Six (6) out of six (6) residents did not have a current written record of care on file. A citation will be issued.

Medication Review: The LPA inspected medication storage areas. Medications were observed to be inaccessible to unauthorized individuals. Medication Administration Records (MARs) are being maintained by the facility.

The Administrator was also issued Technical Advisories and Violations for violations that did not pose an immediate threat to residents in care.

An exit interview was conducted with Administrator Pergantis in which this report was reviewed and a copy was provided, along with the LIC 858, LIC 859 and instructions on appeal rights. LPA addressed Administrator questions relating to the report.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/10/2024 01:34 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 10/10/2024 at 12:34 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: RWINS ELDERLY'S HAVEN
FACILITY NUMBER: 331880563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews and record review, the licensee did not comply with the section cited above in two out of two staff members, S1 and S2 who did not have the above required training complted. According to Administrator the training has been completed. S2 was interviewed & reported they have had dementia training (3 hours) several months ago. S2 could not recall when other training was completed. S3 was interviewed & could not recall when the training was completed. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 11/10/2024
Plan of Correction
1
2
3
4
Administrator stated the staff training will be completed and proof of training will be submitted to the Department by the POC due date.
Type B
Section Cited
CCR
87467(a)(3)
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 6 out of 6 residents who did not have a current written record of care. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 11/10/2024
Plan of Correction
1
2
3
4
Administrator stated written records of care will be completed and copies will be provided to the Department as proof.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3