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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413059
Report Date: 08/09/2024
Date Signed: 08/09/2024 04:22:44 PM

Document Has Been Signed on 08/09/2024 04:22 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:PEACE AND JOY RCFEFACILITY NUMBER:
336413059
ADMINISTRATOR/
DIRECTOR:		CECILE JIMENOFACILITY TYPE:
740
ADDRESS:26560 HEMPSTEAD COURTTELEPHONE:
(951) 672-1301
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY: 6CENSUS: 6DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Favieruth Jimeno, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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On 08/09/2024 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection/1 year required visit. LPA met with Administrator Favieruth Jimeno, and explained the purpose of the visit. The facility is licensed to serve (6) non ambulatory, of which 1 may be bedridden in bedroom #1 or #4 only. The facility has an approved hospice waiver for 2. The facility currently has 4 residents receiving hospice services. There are 2 exception requests that were submitted.

The home is a single story structure consisting of 4 bedrooms and 2 bathrooms, kitchen, garage, backyard, dining area and family room. There are no pools or bodies of water on the premises. The hot water temperature was tested and measured at 109-110 degrees Fahrenheit. The facility was observed to be clean and clutter free. The facility was observed to have the required postings such as personal rights, CCL complaint and LTCO poster. The food supply was adequate as the facility was observed to have a 2 day supply of perishable and a 7 day supply of non perishable food items.

The medications and sharp objects in the locked cabinet located inside the kitchen, The facility has a fully charged fire extinguisher, and the smoke and carbon monoxide detectors were tested and were observed to be operable. The facility is required to conduct the emergency disaster drills on a quarterly basis, the last drill was conducted on 04/20/24. Deficiency cited, as the drill should have been conducted in July 2024.

A records review was conducted on both staff and resident files, each file reviewed (3) residents were observed to have a medical assessment, and appraisals. Staff records reviewed (3) were observed to have current CPR certification, with all staff having obtained proper fingerprint clearance and to be associated to the facility. The Administrator was observed to have a valid administrator certificate, which expires April 2025.

The facility has an ample supply of personal protective equipment. There are no known guns or ammunition on the premises. LPA conducted a file review and as of 08/01/24 the annual licensing fees have not been
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: PEACE AND JOY RCFE
FACILITY NUMBER: 336413059
VISIT DATE: 08/09/2024
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paid, as they are due by 08/21/24. During today's visit LPA followed up regarding the fees, and provided the PIN so that the fees could be paid electronically.

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

An exit interview was conducted and a copy of this report, appeal rights, and proof of corrections form (LIC9098) was provided to Administrator Favieruth Jimeno.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/09/2024 04:22 PM - It Cannot Be Edited


Created By: Javina George On 08/09/2024 at 02:15 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: 08/09/2024

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 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: 08/10/2024
Plan of Correction
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The Licensee agrees to conduct an emergency disaster drill to satisfy the required quarterly drills. 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: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024


LIC809 (FAS) - (06/04)
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