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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423324
Report Date: 01/24/2025
Date Signed: 01/24/2025 05:02:50 PM

Document Has Been Signed on 01/24/2025 05:02 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:PARTNERS N CARE SENIOR RESIDENCEFACILITY NUMBER:
336423324
ADMINISTRATOR/
DIRECTOR:		BEVERLEE VAUGHANFACILITY TYPE:
740
ADDRESS:5873 BUD COURTTELEPHONE:
(951) 213-6314
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 6DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Beverlee Vaughan, Administrator & Karin Vaughn TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card.

Resident record review began- Five (5) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 120.0 degrees F with warning labels posted. Laundry facilities and a locked cabinet is present for storing laundry soap in the laundry room and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location.



Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. Foods are dated to assure safety. Food prep areas are clean and organized.

LPA began review of employee records- Four (4) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current.
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SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PARTNERS N CARE SENIOR RESIDENCE
FACILITY NUMBER: 336423324
VISIT DATE: 01/24/2025
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LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan however LPA observed two (2) bedridden residents and LPA interviewed second bedridden resident. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 01/24/2024. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 12/7/2024.

LPA allocated time to prepare this report for delivery.

Based on the information received during this visit today, there is one deficiency is being cited with Civil penalties for $500 per Title 22, Division 6 of The California Code of Regulations.

This report, 809-D, LIC421IM, Appeal Rights was reviewed with and a copy provided to the facility representative at the time of the exit interview.

LPA has requested updates to the following documents to be submitted to the CCLD by 1/25/2025: LIC 500, and updated floor plan.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/24/2025 05:02 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 01/24/2025 at 04:37 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: PARTNERS N CARE SENIOR RESIDENCE
FACILITY NUMBER: 336423324

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in which LPA observed two clients that are bedridden and Fire Inspection states 1 bedridden is approved which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/25/2025
Plan of Correction
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Licensee will submit LIC200 to CCLD to increase number of bedridden clients by POC due date.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
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