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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412432
Report Date: 02/25/2025
Date Signed: 02/25/2025 12:55:27 PM

Document Has Been Signed on 02/25/2025 12:55 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:FRIENDS HOME CARE AT MORGAN VALLEYFACILITY NUMBER:
336412432
ADMINISTRATOR/
DIRECTOR:		RICHARD & JENNIFER FRIENDSFACILITY TYPE:
740
ADDRESS:45165 RIDEAU STREETTELEPHONE:
(951) 383-8038
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY: 6CENSUS: 5DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:34 AM
MET WITH:Asuncion Buscaino, Caregiver TIME VISIT/
INSPECTION COMPLETED:
01:05 PM
NARRATIVE
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On 02/25/2025, Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA met with Caregiver Asuncion Buscaino and informed her of the purpose of the visit. The administrator's were unable to come to the facility as they were out of state. During the visit, there was five (5) residents and two (2) staff present. LPA verified the contact information that the department has on file to be accurate.

The facility has an approved fire clearance to for six (6) non-ambulatory residents over the age of 60, an approved hospice waiver for (4) residents. There are currently (2) residents receiving hospice services. Prior to coming to the facility LPA conducted a file review and observed that on 02/24/25 the facility annual licensing fees have not been paid. The fees are due by 03/09/25, LPA provided the following PIN 120899, should the Administrator wish to pay the fees electronically.

LPA observed residents to be asleep and (1)to have a visit with hospice. Records review of staff present ha a criminal record clearance and to be associated to the facility in addition to having on file valid first CPR/ first aid certification. LPA conducted a records review from the Administrators Certification Bureau and observed under active certificates list as well as pending renewals application for nothing to be found for both Richard and Jennifer Friend. Both Richard and Jennifer do not possess a valid administrator certificate. Deficiency cited. The resident files had the required assessments, and admissions agreement.

The facility has (2) fire extinguishers that were checked April 2024. There are no pools or bodies of water on the premises. The food supply was observed to be sufficient as there was a 2-day supply of perishables and and 7-day supply of non-perishable food items. The governing body was observed to be in good standing.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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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: FRIENDS HOME CARE AT MORGAN VALLEY
FACILITY NUMBER: 336412432
VISIT DATE: 02/25/2025
NARRATIVE
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The facility was observed to be clean, clutter and odor free. Indoor and outdoor passageways are free of obstructions and the physical plant is in good repair. The sharps, medications and other hazardous items were observed to be locked and inaccessible to residents in care. The hot water temperature in the resident bathrooms measured at 112- and 116.9-degrees Fahrenheit.

The facility was observe to have valid liability insurance that expires on 12/18/25, in addition to having the required postings. The emergency disaster plan LIC610E requires to be updated as the form used was from 2007. An updated emergency disaster plan is due to the department by 5pm on 03/04/25. In addition the Administrator's are encouraged to conduct a review of records for both staff and residents to ensure that they are in compliance. LPA provided the LIC311F-RCFE, Records to be maintained at the facility for reference.

There was no record of the facility conducting emergency disaster drills, as there were no logs available for LPA to review during today's visit. deficiency cited.

Based on today's inspection a citation will be issued on the attached 809D, in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted where a copy of this report, and appeal right and LIC9098--proof of corrections form was reviewed and provided to caregiver Asuncion Buscaino.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/25/2025 12:55 PM - It Cannot Be Edited


Created By: Javina George On 02/25/2025 at 12:23 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: FRIENDS HOME CARE AT MORGAN VALLEY
FACILITY NUMBER: 336412432

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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The Licensee agrees to conduct an emergency disaster drill as well as document it. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/25/2025 12:55 PM - It Cannot Be Edited


Created By: Javina George On 02/25/2025 at 12:23 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: FRIENDS HOME CARE AT MORGAN VALLEY
FACILITY NUMBER: 336412432

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on obsevation, interview and recrods review, the licensee did not comply with the section cited above in 2 out of 2 times as both of the administrators on file do not posess valid administrator certification which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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The Licensee agrees to have both administrator's complete the renewal certification. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
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