331881322-4-4-2025-18-AS-JGEE-DFEUS5-20250404154945

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881322
Report Date: 04/04/2025
Date Signed: 04/04/2025 03:49:53 PM

Document Has Been Signed on 04/04/2025 03:49 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:	DELICARE I HEALTH SERVICES, INC		FACILITY NUMBER:	331881322
ADMINISTRATOR/ DIRECTOR:	AWAD, SAMEH		FACILITY TYPE:	740
ADDRESS:	27143 SETTLEMENT STREET		TELEPHONE:	(909) 559-7200
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92585
CAPACITY: 6		CENSUS: 6	DATE:	04/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:17 PM
MET WITH:	Elossia Santiago, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	04:00 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	On 04/04/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facilty to conduct a 1 year required inspection. LPA was greeted and granted entry by caregiver Christina Gariby. The Administrator Sameh Awad was unavailable to come to the facility but was available via telephone and virtually. At the time of the visit there was (2) staff and (6) residents present. The facility has an approved hospice waiver for (3) with a total of (1) resident currently receiving services. LPA toured the interior and exterior of the facility. LPA observed for there to be activities for the residents such as games, as well as a putting green. The facility was observed to be clean, clutter and odor free. LPA observed the facility was observed to have a sufficient food supply of a 2-day supply of perishable, and 7-day supply of non-perishable food items. The combined smoke and carbon monoxide detectors were tested and were observed to be operational. The hot water measured at 113.7-114.3 degrees Fahrenheit. The emergency disaster drills are being conducted on a monthly basis with, one being due by the end of this month (April 2025). Resident medication was observed to be locked in two (2) kitchen cabinets, next to the refrigerator. Disinfectants, cleaning solutions, and detergents are stored inside the locked laundry room. The facility has a closet with additional linen, towels and comforters available for the residents. A records review of staff and resident files was conducted, on the computer as they are electronic. Resident files reviewed have signed physician reports, video surveillance consents and admission agreements. All staff present have criminal record clearance, were associated to the facility and were in possession of valid first aid certification. The administrator Sameh Awad's certificate expires on 4/8/25, and he is in the process of renewing with 10 hours

NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: DELICARE I HEALTH SERVICES, INC	FACILITY NUMBER: 331881322
	VISIT DATE: 04/04/2025

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remaining, that has been scheduled for next Wednesday 4/9/25, and then the renewal packet will be submitted. The facility is using online training software such as Career Smarts and Caring Data to complete required training. The facility was observed to have the required postings such as theft and loss, personal rights.

The annual fees were paid during today's visit LPA provided PIN#830401 to the Administrator, for them to be paid electronically. The facility sketch needs to updated to reflect the cameras and their location and the staff area/room as well as staff office that is located inside the garage. The updated facility sketches are due no later than Tuesday 4/8/25 by 5pm.

There were no citations issued during today's visit.

An exit interview was conducted and a copy of this report, LIC811-Confidential names list was reviewed and provided to Caregiver Eloisa Santiago.

NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC809 (FAS) - (06/04)

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