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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530190
Report Date: 04/07/2025
Date Signed: 04/07/2025 03:20:18 PM

Document Has Been Signed on 04/07/2025 03:20 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:EVERLAST ASSISTED LIVING LLCFACILITY NUMBER:
335530190
ADMINISTRATOR/
DIRECTOR:		LANGI, SOPHEAREAKFACILITY TYPE:
740
ADDRESS:30045 AUDELO STTELEPHONE:
(951) 579-1120
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 5CENSUS: 4DATE:
04/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Brett Powell, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to complete the annual inspection. LPA met with Administrator Brett Powell for a Residential Care Facility for the Elderly (RCFE) for five (5) non-ambulatory residents, one (1) resident may be bedridden. LPA Farlow introduced self and explained the purpose of the visit. The administrator Brett, provided LPA with a space to work and conducted a tour of the facility.

The facility has four (4) bedrooms and two (2) bathrooms. There are four (4) resident bedrooms, two (2) resident bathrooms, a kitchen, a living room, a dining area, a laundry room, a backyard, and an attached garage. LPA toured the interior and exterior areas of the facility. The following were inspected:

Resident Bedrooms: All bedrooms have the required bedding and furniture, such as clean mattresses/linens, mattress covers, night stands, dressers, chairs, and lighting.

Resident Bathrooms: The bathrooms appliances were operating in safe and sanitary condition. The water temperature was measured by LPA, the thermometer read at 131.0, 117.2, and 133.4 degrees F. Licensee adjusted the water heater immediately. A deficiency was cited.

Kitchen and Dining Areas: Utensils and dishware are in good repair and readily available for residents in care. Kitchen appliances and counter tops were free of debris and in good repair. The chemicals were locked underneath the kitchen sink. The sharps were locked in the kitchen cabinet.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2025
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 9
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EVERLAST ASSISTED LIVING LLC
FACILITY NUMBER: 335530190
VISIT DATE: 04/07/2025
NARRATIVE
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Medication: The location for medications was locked and secured in the hallway closet. LPA audited 3 out of 3 residents MARs and noticed the Licensee and staff do not have a printable document showing the date and time medication was issued. LPA observed the facility uses an app for charting which was not completed for the 8am meds at 10:38AM. LPA observed the Centrally Stored Medication Log had medication that were not logged or medication that was in the secured container but not listed on the MARs. A deficiency was cited.

Laundry Room/Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies were available for each resident. The laundry room contains chemicals and was securely locked.

Backyard: There are no bodies of water in the backyard. There is a covered area with seating for the all the residents. All passageways were free from obstruction.



Facility Postings, Fire extinguisher, First aid: There are two (2) charged fire extinguishers in the facility. LPA observed the fire extinguisher was last inspected on 3/13/2025. LPA observed operating smoke detectors and carbon monoxide alarms. LPA observed the facility has not completed a fire/emergency drill since September 2024. A technical violation was issued. The home does not have any firearms and or ammunition. LPA observed required postings including the visitation polices, emergency/disaster contact numbers, complaint procedures, labor laws, and personal rights. LPA observed the licensee did not update or review the LIC610E (Emergency Disaster Plan for Residential Care Facilities For The Elderly. A technical violation issued. LPA observed a complete first aid kit, but licensee did not have a current first aid manual. A technical advisory issued. The facility has a working telephone for resident use.

Record Review: LPA reviewed three (3) out of (3) residents files for Admission Agreements, Physician Reports, Needs and Services Plans, Identification and Emergency contact sheet. LPA observed resident file complete and maintained. Staff Files were not readily accessible to LPA during the visit. Administrator stated staff records are being updated. LPA could not verify CPR/First aid training, Health Screening, Personnel Records, Criminal Records Clearances, Background Statements and Fingerprinting, Annual Training. LPA did have a current guardian roster which showed staff working were cleared. A deficiency was cited for staff records not being available. LPA observed the facility did not have a Infection Control Plan available for review. Administrator stated the facility folder was being updated. A technical violation issued.

Based on the observations made during today’s visit, three deficiencies, three technical violation, and one technical advisory were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), (LIC809C), (LIC809D), (LIC9102TV), (LIC9102TA) and appeal rights was discussed and provided to Administrator Brett Powell.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 04/07/2025 03:20 PM - It Cannot Be Edited


Created By: Lavette Farlow On 04/07/2025 at 02:28 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: EVERLAST ASSISTED LIVING LLC
FACILITY NUMBER: 335530190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview, the licensee did not comply with the section cited above in 2 out of 3 area in the home by not ensuring the tap water measure within regulations. The reguired temperature is 105-120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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The Administrator agrees to post signs stating "Caution Hot Water", create a system to monitor the water temperature, and the adminstrator immediately adjusted the water heater. The adminstrator agrees to complete all the POC by due date.
Type A
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 out of 3 staff by not ensuring the staff personnel records are available for review by CCLD or any other authorized agency, LPA was not able to verify health screening for staff or any pertinent information which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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Administrator agrees to have all staff personnel records available for review at the facility for CCLD and other authorized agency by POC 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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 04/07/2025 03:20 PM - It Cannot Be Edited


Created By: Lavette Farlow On 04/07/2025 at 02:28 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: EVERLAST ASSISTED LIVING LLC
FACILITY NUMBER: 335530190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 out of 3 residents MARs, by not ensuring staff sign and date when medication is dispensed, and ensuring all medication is properly listed or removed if discontinued which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2025
Plan of Correction
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The Administrator agrees to complete a staff training regarding the importance of logging medication, signing and date the medication was dispensed and will review the regulations and provide LPA with a sign in sheet of all saff who completed the training.
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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2025


LIC809 (FAS) - (06/04)
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