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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880633
Report Date: 03/18/2024
Date Signed: 03/18/2024 04:16:15 PM

Document Has Been Signed on 03/18/2024 04:16 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:CALIFORNIA MANOR GUEST HOME #1FACILITY NUMBER:
331880633
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:8536 & 8548 CALIFORNIA AVETELEPHONE:
(786) 219-6008
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 12CENSUS: 12DATE:
03/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Formin "Chris" Cornista - StaffTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with staff Formin "Chris" Cornista and informed him of the purpose of today's inspection. Below is a summary of what was observed:

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 121.8 degrees in building 8536 and 120.2 degrees in building 8548. Deficiency cited.. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives were locked away from residents' reach. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. LPA Colvin observed numerous areas of the facility's backyard which had discarded/unused furniture, including multiple mattress and box springs. Deficiency cited.
Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 12 ambulatory residents, two of which may be non-ambulatory.

Staffing & Staff Records: LPA Colvin observed that upon arrival at the facility, there was no staff present in the 8548 building, though there were residents present in that building. Staff for that building did not arrive until 2:48pm, and even then they spent the majority of the inspection in the staffed 8536 building. Deficiency cited. Lack of supervision is considered a serious deficiency which results in an immediate civil penalty of $500, which LPA Colvin will be assessing today. LPA Colvin was unable to review the Administrator's file as staff could not locate it. Deficiency cited. LPA Colvin observed that both staff files reviewed (S1 & S2) did not have training included in the file. Deficiency cited. Additionally, S1's CPR/First Aid Certification was expired and there was no certification in S2's file. Deficiency cited.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2024
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 7
Document Has Been Signed on 03/18/2024 04:16 PM - It Cannot Be Edited


Created By: Crystal Colvin On 03/18/2024 at 03:22 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: CALIFORNIA MANOR GUEST HOME #1
FACILITY NUMBER: 331880633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 of 2 staff, which poses an immediate safety risk to persons in care. LPA Colvin observed that both staff present during today's inspection did not have a current CPR certification in their files.
POC Due Date: 03/19/2024
Plan of Correction
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Licensee to obtain current CPR certification for staff. Copy to be provided to LPA Colvin by Plan of Correction date of 3/19/24.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in2 out of 2 faucets tested, which poses an immediate safety risk to persons in care. LPA Colvin tested one bathroom faucet in each building. The faucet in building 8536 tested at 121.8 degrees and the faucet in building 8548 measured at 120.2 degrees
POC Due Date: 03/19/2024
Plan of Correction
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Licensee agrees to adjust the hot water tempurature in both buildings and re-test the hot water and ensure it is between 105 - 120 degrees. Licensee may self-certify to LPA Colvin once complete. Due by Plan of Correction date of 3/19/24.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 03/18/2024 04:16 PM - It Cannot Be Edited


Created By: Crystal Colvin On 03/18/2024 at 03:22 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: CALIFORNIA MANOR GUEST HOME #1
FACILITY NUMBER: 331880633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 of 3 staff files which poses/posed a potential safety risk to persons in care. LPA Colvin observed that there was no file for the Administrator at the facility.
POC Due Date: 04/01/2024
Plan of Correction
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Licensee agrees to ensure a copy of the Administrator's file is present at the facility. Licensee may self-certify to LPA Colvin once they have added the file to the facility. Due by Plan of Correction date of 4/1/24.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 of 5 resident files, which poses a potential health risk to persons in care. LPA Colvin observed that R2 & R4 both have Physician's Reports for other facilties and are over 1 year old from date of Admission.
POC Due Date: 04/01/2024
Plan of Correction
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Licensee agrees to obtain updated Physician's Report for R2 & R4. Licensee to provide updated reports to LPA Colvin by Plan of Correction date of 4/1/24. Licensee to additionally self-audit files to ensure records are up to 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:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/18/2024 04:16 PM - It Cannot Be Edited


Created By: Crystal Colvin On 03/18/2024 at 03:22 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: CALIFORNIA MANOR GUEST HOME #1
FACILITY NUMBER: 331880633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 of 5 resident files, which poses a potentia personal rights risk to persons in care. LPA Colvin observed that there is no Admissions Agreement on file for R1. Additioinally, R3's Admissions Agreement is for a different licensed facility at an entirely different location (owned by same Licensee).
POC Due Date: 04/01/2024
Plan of Correction
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Licensee to complete an Admissions Agreement with R1 & R3 and any representative they may have. Licensee may self-certify to LPA Colvin once complete. Due by Plan of Correction date of 4/1/24
Type B
Section Cited
CCR
87307(a)
Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 area of the facility, which poses a potential personal rights risk to persons in care. LPA Colvin observed multiple areas in the backyard of the facility which was littered with discarded and unused furniture.
POC Due Date: 04/01/2024
Plan of Correction
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Licensee agrees to have discarded/unused furniture removed. Licensee to provide LPA Colvin with photographs of the clean up backyard. Due by Plan of Correction date of 4/1/24.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 03/18/2024 04:16 PM - It Cannot Be Edited


Created By: Crystal Colvin On 03/18/2024 at 03:46 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: CALIFORNIA MANOR GUEST HOME #1
FACILITY NUMBER: 331880633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.2(a)(4)
Additional Personal Rights of Residents in Privately Operated Facilities: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 of 2 buildings, which poses an immediate safety risk to persons in care. LPA Colvin observed that from at least 2:15pm - 2:48pm, there was no staff present in the 8548 building.
POC Due Date: 03/19/2024
Plan of Correction
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Licensee to formulate plan to ensure both buildings are staffed at all times that residents are present. Licensee to submit plan to LPA Colvin by Plan of Correction date of 3/19/24.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 03/18/2024 04:16 PM - It Cannot Be Edited


Created By: Crystal Colvin On 03/18/2024 at 03:49 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: CALIFORNIA MANOR GUEST HOME #1
FACILITY NUMBER: 331880633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records: (c) Licensees shall maintain in the personnel records verification of required staff training and orientation.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 of 2 staff files, which poses a potential health, safety or personal rights risk to persons in care. LPA Colvin observed that neither staff file available for review contained training for staff.
POC Due Date: 04/01/2024
Plan of Correction
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Licensee to update staff files to include training. Licensee may self-certify once complete.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
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: CALIFORNIA MANOR GUEST HOME #1
FACILITY NUMBER: 331880633
VISIT DATE: 03/18/2024
NARRATIVE
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Resident Records: LPA Colvin reviewed the files for 5 residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin observed that Resident One (R1) did not have an Admissions Agreement in their file, and R3's Admissions Agreement is for a different licensed facility at an entirely different location (owned by same Licensee). Deficiency cited. LPA Colvin observed that R2 & R4 both have Physician's Reports for other facilities and are over 1 year old from date of Admission. Deficiency cited.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in the kitchen and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions.



Due to time constraints, the annual will be continued on a later date. Observations were documented and will be addressed during the annual continuation.

An exit interview was conducted with staff Formin "Chris" Cornista and a copy of this report, LIC809D, LIC421IM, LIC9098 Proof of Corrections, and appeal rights were provided
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC809 (FAS) - (06/04)
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