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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880980
Report Date: 02/13/2024
Date Signed: 02/13/2024 04:06:30 PM

Document Has Been Signed on 02/13/2024 04:06 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:MAMA ANGELINA COCONOCHOFACILITY NUMBER:
331880980
ADMINISTRATOR:GONZALEZ, MARIA ROSARIOFACILITY TYPE:
740
ADDRESS:862 PIKE DRIVETELEPHONE:
(951) 335-1239
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 6CENSUS: 6DATE:
02/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Gonzalez, AdministratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility for a complaint visit. The LPA met with Administrator, Maria Gonzalez, and informed her of the purpose for the visit.

During the visit the LPA toured and inspected the property. The LPA observed a lock on the exterior gate. No secondary exit was available. In addition, a bedridden resident was observed to be in care. Resident Three's (R3's) Physician's Report for Residential Care Facilities for the Elderly (RCFE) noted the resident was non-ambulatory and bedridden. The resident agreed to attempt to reposition themself in bed, though was unable to physically do so. The facility does not have an approved fire clearance for a bedridden resident.

During an inspection of the facility's food supply the LPA observed medications in the facility's refrigerator. The medications were not maintained secured from any unauthorized individuals, rather was stored on the right-side door of the kitchen refrigerator. The backyard fence had missing and/or broken wooden panels and the care staff were observed to walk through the fence and into the backyard of another home. According to Administrator Gonzalez, she owns the property behind the facility. She stated her staff do take their breaks at the other facility. Administrator Gonzalez stated the fence broke during a storm last week.

These violations pose immediate and potential threats to the health, safety, and personal rights of the residents in care. Citations and civil penalties will be issued.

An exit interview was conducted; this report was reviewed with Administrator Gonzalez over the phone, and a copy was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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 02/13/2024 04:06 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 02/13/2024 at 12:49 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: MAMA ANGELINA COCONOCHO
FACILITY NUMBER: 331880980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2024
Section Cited
CCR
87203

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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. This requirement was not met, as evidenced by: Based on observation, the Licensee did not ensure the facility was
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Staff removed the lock from the gate prior to the conclusion of the LPA's visit.
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maintained in conformity with the regulations adopted by the State Fire Marshal. The LPA observed a lock on the exterior gate. No secondary exit was available. This posed an immediate threat to the health and safety of the residents in care.
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Type A
02/14/2024
Section Cited
CCR87202(a)(2)

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FIRE CLEARANCE: (a) All facilities shall maintain a fire clearance approved by... the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the...licensee shall...obtain an appropriate fire clearance approved by...the State Fire Marshal. (2) Bedridden persons. This requirement was
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The Administrator stated a copy of a 3-day eviction notice will be submitted to the Department by the POC due date.
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not met, as evidenced by: Based on records, the Licensee didn't ensure an appropriate fire clearance was obtained prior to accepting a bedridden person into care. R3's Physician's Report noted R3 is non-ambulatory & bedridden. R3 was unable to reposition themself in bed.
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/13/2024 04:06 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 02/13/2024 at 01:31 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: MAMA ANGELINA COCONOCHO
FACILITY NUMBER: 331880980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/13/2024
Section Cited
CCR
87465(h)(2)

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INCIDENTAL MEDICAL AND DENTAL CARE: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe & locked place that isn't accessible to persons other than employees responsible for the supervision of the medication.
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The Administrator stated a lockbox will be purchased for the medications and a receipt will be submitted to the Department.
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This requirement was not met, as evidenced by: Based on observation, the Licensee did not ensure refrigerated medications were kept in a safe & locked place. LPA observed medications in the facility's refrigerator. The medications were not maintained secured from any unauthorized individuals.
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


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