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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880566
Report Date: 04/28/2021
Date Signed: 04/28/2021 02:41:36 PM

Document Has Been Signed on 04/28/2021 02:41 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:FIRST CHOICE SENIOR LIVINGFACILITY NUMBER:
331880566
ADMINISTRATOR:RECINTO, MONTANO OFACILITY TYPE:
740
ADDRESS:34796 MYOPORUM LNTELEPHONE:
(951) 599-4305
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 6CENSUS: 5DATE:
04/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Montano Recinto, LicenseeTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Deborah Mullen conducted an unannounced visit on this date. LPA met with Mon Recinto, Licensee. The purpose of the visit was to follow up on information obtained during the investigation of complaint control # 18-AS-20210315132120.

During the investigation it was discovered that licensee accepted resident 1 (R1) prior to conducting a pre-placement appraisal, that staff were hiding medication in R1’s food and that incidents that transpired during the time R1 was in placement were not reported to Community Care Licensing.

In addition, during the inspection LPA observed the hall closet and the kitchen pantry being used as staff bedrooms, a key deadbolt installed on the front door and three latches installed on the interior of the front door, preventing residents from exiting the home. This poses an immediate health and safety risk to residents in care.

As a result of the above stated information and in accordance with Title 22 regulations, citations are being as detailed on the attached LIC 9099D.

An exit interview was conducted and a copy of this report and appeal rights were reviewed with and provided to the Licensee.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Deborah Mullen
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2021
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 04/28/2021 02:41 PM - It Cannot Be Edited


Created By: Deborah Mullen On 04/28/2021 at 02:02 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: FIRST CHOICE SENIOR LIVING
FACILITY NUMBER: 331880566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2021
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.
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Licensee will review Section 87211 and submit a self-certification of review and understanding of the regulation. This will be submitted to the department by 5/7/21.
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This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not being met as evidenced by: Incidents involving resident 1(R1) whereby resident was in a highly agitated state and whereby 911 was called and R1 was sent to the hospital were not reported to the Department.
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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:Karen Clemons
LICENSING EVALUATOR NAME:Deborah Mullen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2021


LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 04/28/2021 02:41 PM - It Cannot Be Edited


Created By: Deborah Mullen On 04/28/2021 at 02:00 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: FIRST CHOICE SENIOR LIVING
FACILITY NUMBER: 331880566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2021
Section Cited
CCR
87465(a)(6)(D)

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Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (D) Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication.
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Licensee will review Section 87465 and submit a self-certification of review and understanding of the regulation. In addition an in-service training will be conducted with staff. This will be submitted to the department by 5/7/21.
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This requirement was not being met as evidenced by: The licensee stated R1’s medication was being hidden in R1’s food as R1 did not like taking the medication.
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Type B
04/29/2021
Section Cited
CCR87203

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Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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Licensee will empty the closet and pantry and discontinue use as living accomodations. Proof of correction will be submitted to licensing by 4/29/21.
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This requirement was not being met as evidenced by: During a facility inspection on 4/28/21, LPA Mullen observed a hall closet and a pantry being used as staff bedrooms. This poses a potential health and safety risk.
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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:Karen Clemons
LICENSING EVALUATOR NAME:Deborah Mullen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2021 02:41 PM - It Cannot Be Edited


Created By: Deborah Mullen On 04/28/2021 at 01:55 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: FIRST CHOICE SENIOR LIVING
FACILITY NUMBER: 331880566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2021
Section Cited
CCR
87468.1(a)(6)

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Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.
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Per the licensee, the three latches and keyed deadbolt will be removed and proof of removal submitted today, 4/28/21.
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This requirement was not being met as evidenced by: During a facility inspection on 4/28/21, LPA observed the front door to have three locks on the interior of the front door. In addition, LPA observed a keyed deadbolt on the front door. This poses an immediate health and safety risk to residents in care.
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Type B
05/07/2021
Section Cited
CCR87456(a)(2)

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Evaluation of Suitability for Admission: (a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.
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Licensee will review Section 87456 and submit a self-certification of review and understanding of the regulation. This will be submitted to the department by 5/7/21.
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This requirement was not being met as evidenced by: Licensee stated a pre-admission’s appraisal was not completed for R1 prior to admission to the facility.
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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:Karen Clemons
LICENSING EVALUATOR NAME:Deborah Mullen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2021


LIC809 (FAS) - (06/04)
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