Community Care Licensing

Document Has Been Signed on 08/23/2022 05:18 PM - It Cannot Be Edited

FACILITY NAME:	CHICAGO HOPE ASSISTED LIVING		FACILITY NUMBER:	336405788
ADMINISTRATOR:	KAREN COCCHIARO		FACILITY TYPE:	740
ADDRESS:	25858 NEW CHICAGO		TELEPHONE:	(951) 663-8514
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY: 6		CENSUS: 6	DATE:	08/23/2022
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Deanna Maegillivary - Caregiver		TIME COMPLETED:	05:30 PM

SUPERVISORS NAME: Joel Esquivel LICENSING EVALUATOR NAME: Crystal Colvin LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022

Link to Parent Document Below:

FACILITY NAME: CHICAGO HOPE ASSISTED LIVING	FACILITY NUMBER: 336405788
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/02/2022 Section Cited CCR 87507(c)	1 2 3 4 5 6 7	Admission Agreements: (c) Admission agreements shall be signed and dated... no later than seven days following admission.... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to have a meeting with R1 and R1's representative (per R1's request) to go over the Admissions Agreement and answer any questions they may have in order to assist with completion of the document. Licensee to self-certify to LPA Colvin once complete. Due by Plan of Correction date of 9/2/22.
	8 9 10 11 12 13 14	Based on record review, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin observed that R1 has been in the facility for 10 days but does not have a signed Admissions Agreement. This is a potential personal rights violation of R1.	8 9 10 11 12 13 14
Type B 09/02/2022 Section Cited CCR87468.2(a)(11)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities : (a) In addition to the rights listed ...residents in ...facilities...shall have all of the following personal rights:(11) To be fully informed, prior to or at the time of admission, of all rules... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to go over facility rules with R1 and their representative and obtain signature of each proving that this was discussed. Licensee may self-certify to LPA Colvin once complete. Due by Plan of Correction date of 9/2/22.
	8 9 10 11 12 13 14	Based on interviews and record review, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin observed that R1 did not have signed Admissions Agreement and interviews revealed confusion regarding house rules. This is a potential personal rights violation of R1.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Joel Esquivel LICENSING EVALUATOR NAME: Crystal Colvin LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022

Link to Parent Document Below:

FACILITY NAME: CHICAGO HOPE ASSISTED LIVING	FACILITY NUMBER: 336405788
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/02/2022 Section Cited HSC 1569.185(e)	1 2 3 4 5 6 7	Fees for license or applications; use of revenues; collected; denial or forfeiture: (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement was not met by:	1 2 3 4 5 6 7	Licensee agrees to pay all outstanding fees due to Commuity Care Licensing. Licensee may self-certify to LPA Colvin once fees have been paid. Plan of Correction due date of 9/2/22.
	8 9 10 11 12 13 14	Based on record review, the Licensee did not comply with the above Health & Safety Code with licensing fees ($742 total). LPA Colvin observed that the facility past due licensing fees for annual fees as well as late fee for 2021. This is a potential safety risk to residents in care.	8 9 10 11 12 13 14
Type B 09/02/2022 Section Cited CCR87208(a)	1 2 3 4 5 6 7	Plan of Operation: (a) Each facility shall have and maintain a current, written definitive plan of operation... Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to update records on file with Licensing by submitting an udpated facility sketch as well as current Admissions Agreements and other documents/forms that have changed since facility was opened. Due by Plan of Correction date of 9/2/22.
	8 9 10 11 12 13 14	Based on record review and observations, the Licensee did not comply with the above regulation with two aspects of the facility. LPA Colvin observed staff room not to be noted in the facility sketch. Additionally, Admissions Agreement currently in use is not on file with Licensing. This is a potential safety concern.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Joel Esquivel LICENSING EVALUATOR NAME: Crystal Colvin LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022