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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530032
Report Date: 10/09/2024
Date Signed: 10/09/2024 12:25:14 PM

Document Has Been Signed on 10/09/2024 12:25 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SAVANT OF JURUPA VALLEYFACILITY NUMBER:
335530032
ADMINISTRATOR/
DIRECTOR:		PATRICK L. MCADOO-MORTONFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 683-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY: 197CENSUS: 155DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator Marc Pacia and Regional Manager Patrick L. MortonTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Office Manager Danielle Garcia and was granted entry to the facility. Licensed capacity is (197) current census (155). LPA was accompanied by Regional Manager Patrick L. Mcadoo Morton, Administrator Marc Pacia and Office Manager Danielle Garcia to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, and the CCL complaint poster, were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated office for client/staff files.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Mary Rico
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SAVANT OF JURUPA VALLEY
FACILITY NUMBER: 335530032
VISIT DATE: 10/09/2024
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Record Review: LPA reviewed (15) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (15) resident medications and (3) hospice files. In addition, LPA audit (10) resident safeguard. The remaining cash balance matched the documentation on the LIC405. LPA also reviewed (10) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

During medication audit, 3 out of the 4 medication carts had lose pills. LPA observed (7) lose pills. LPA requested for the medication to be dispose properly. Medication shall be centrally stored in it's original received container/bubble pack.

Based on the observations made during today’s visit, (1) Type A Deficiency were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Marc Pacia and Regional Manager Patrick L. Mcadoo. Along with a copy of Appeal Rights.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Mary Rico
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/09/2024 12:25 PM - It Cannot Be Edited


Created By: Mary Rico On 10/09/2024 at 11:58 AM
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: SAVANT OF JURUPA VALLEY
FACILITY NUMBER: 335530032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and medication audit, the licensee did not comply with the section cited above in 3 out of the 4 medication carts had lose pills. LPA observed (7) lose pills, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Regional Manager and Administrator stated to train all staff on CCR 87465(h)(5) and submit proof of training log to LPA.
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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024


LIC809 (FAS) - (06/04)
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