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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423909
Report Date: 03/18/2022
Date Signed: 03/18/2022 10:39:19 AM

Document Has Been Signed on 03/18/2022 10:39 AM - 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:CAMPBELL'S LOVING HOME CARE INC.FACILITY NUMBER:
336423909
ADMINISTRATOR:CHARLES CAMPBELLFACILITY TYPE:
740
ADDRESS:18 NAPOLEON RD.TELEPHONE:
(760) 832-7791
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY: 6CENSUS: 6DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Elsie Viray, CaretakerTIME COMPLETED:
10:40 AM
NARRATIVE
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Licensing Program Analysts (LPA) Jesse Gardner made an unannounced visit to conduct an annual inspection with an emphasis on infection control.

LPA met with Caregiver Elsie Viray. Present in the facility during time of visit were 6 clients. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities. LPA discussed infection control practices and procedures with Ms. Viray.

During a review of resident medication, LPA noticed medication not being stored in its original prescribed container. Thus a Type B citation was issued.

An exit interview was conducted and a copy of this report was discussed with and provided to Ms. Viray.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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 03/18/2022 10:39 AM - It Cannot Be Edited


Created By: Jesse Gardner On 03/18/2022 at 09:43 AM
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: CAMPBELL'S LOVING HOME CARE INC.
FACILITY NUMBER: 336423909

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation when reviewing medication storage, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed several medication pills stored in individual one-time use cups.
POC Due Date: 04/01/2022
Plan of Correction
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Licensee agrees to store medication in its original prescribed container, and review the regulation and provide proof that staff received training on the proper storage of medications by providing LPA an email of signed roster by POC 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:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
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