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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881233
Report Date: 05/08/2024
Date Signed: 05/08/2024 12:56:41 PM

Document Has Been Signed on 05/08/2024 12:56 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:ANNACARE2 LLCFACILITY NUMBER:
331881233
ADMINISTRATOR/
DIRECTOR:		BLANCAFLOR, ANNALISAFACILITY TYPE:
740
ADDRESS:20846 SUNDROPS LANETELEPHONE:
(951) 399-0363
CITY:WILDOMARSTATE: CAZIP CODE:
92592
CAPACITY: 6CENSUS: 5DATE:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Caregiver, Milani EncinasTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 5/8/2024, Licensing Program Analyst (LPA), Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Caregiver, Milani Encinas who was informed of the purpose of the visit. Administrator, Annalisa Blancaflor was contacted over-the-phone and informed of LPA's visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents, of which one (1) may be bedridden. The facility also has an approved hospice waver for three (3) residents and LPA was informed none of the current residents are on hospice.

During today's visit, there was five (5) residents and one (1) staff present. LPA toured the facility with Caregiver Encinas. All outdoor pathways were free of obstructions. Outdoor shaded seating area is available for the residents to sit and relax. The facility has an in-ground pool that has an appropriate gate and is secured with a master lock to make it inaccessible for the residents in care. LPA observed residents watching television in the living room. Resident bedrooms have the required bedding, furniture and lighting. Bathrooms are clean and have grab bars near the showers. The facility has a hallway closet filled with clean towels, blankets, and linen, available in different colors for the residents in care. LPA toured the kitchen and observed the facility has a 2-day supply of perishable foods and 7-day supply of non-perishable foods, which are stored in a safe and healthful manner. Cleaning solutions and disinfectants are secured in a locked cabinet in the laundry room. Caregiver Encinas tested the smoke alarms/carbon monoxide detectors and LPA found them to be operational. LPA also observed charged fire extinguishers mounted throughout the facility. Medication is secured in a locked kitchen cabinet. The facility has two (2) living rooms. LPA observed living rooms to be clean and furniture in good condition. LPA reviewed random resident files and observed that residents with a dementia diagnosis had updated physician reports. Residents' personal rights, Long-Term Care Ombudsman's contact information and grievance procedures are posted near the front entrance.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted an a copy of this report was reviewed and provided to Caregiver Encinas.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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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