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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413059
Report Date: 08/31/2021
Date Signed: 08/31/2021 03:36:53 PM

Document Has Been Signed on 08/31/2021 03:36 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PEACE AND JOY RCFEFACILITY NUMBER:
336413059
ADMINISTRATOR:CECILE JIMENOFACILITY TYPE:
740
ADDRESS:26560 HEMPSTEAD COURTTELEPHONE:
(951) 672-1301
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY: 6CENSUS: 5DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Favieruth Jimeno, AdministratorTIME COMPLETED:
03:38 PM
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced annual inspection with an emphasis of infection control. LPA Gardner met with Administrator Favieruth Jimeno and toured the facility.

LPA Gardner inspected the facility and the following was observed: The home is one story, four bedroom, two bath home with a living room, dining room, and kitchen. The smoke/carbon monoxide detectors were tested and observed to be operational. Towels, linens were observed and appeared to be sufficient for residents in use. The residents rooms were furnished with bed, dresser, chair and lighting for residents comfort. The residents medication are stored in a locked cabinet in the kitchen. The knives are kept with the cleaners under the kitchen sink in a locked cabinet. LPA Gardner observed the kitchen to be supplied with adequate plates, cups, dishes and silverware, as well as pots, pans and serving bowls for residents use. The food supply was inspected and met the minimum requirement of 7 days non-perishable and 3 days perishable foods. The backyard is fully fenced and has chairs and shade for residents use.

During the inspection LPA Gardner asked Ms. Jimeno about the residents. Ms. Jimeno stated that the facility is approved for 6 residents, of which 2 can be on hospice. Ms. Jimeno indicated that she currently has 3 residents on hospice. A records review indicated that the 3rd hospice resident, R1, was admitted on 5/31/21, and began receiving hospice care on 8/10/21. During the inspection LPA Gardner reviewed infection control practices and procedures with Ms. Jimeno.

An exit interview was conducted and a copy of this report, along with LIC 809D and appeal rights were reviewed with and provided to Ms. Jimeno.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2021
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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Document Has Been Signed on 08/31/2021 03:36 PM - It Cannot Be Edited


Created By: Jesse Gardner On 08/31/2021 at 02:53 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: PEACE AND JOY RCFE
FACILITY NUMBER: 336413059

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2021
Section Cited

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CCR 87632(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department.
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This requirement was not met as evidenced by: Based on interview, and record interview, licensee failed to ensure an approved hospice waiver was in place upon retaining a resident on hospice. This poses an immediate health and safety to residents in care.
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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:Reyna Lacey
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2021


LIC809 (FAS) - (06/04)
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