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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424391
Report Date: 04/18/2022
Date Signed: 04/18/2022 03:32:50 PM

Document Has Been Signed on 04/18/2022 03:32 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:NEW HOPE RESIDENTIAL ELDER CARE, LLCFACILITY NUMBER:
336424391
ADMINISTRATOR:ANNIE JANE MIKENASFACILITY TYPE:
740
ADDRESS:39520 BONAIRE WAYTELEPHONE:
(951) 600-2941
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 5CENSUS: 5DATE:
04/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Edward Mikenas, StaffTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 12:00 PM, LPA was met by Rogelio Zaraga, father of the Licensee and explained the purpose of the visit. Present in the facility during time of visit were one (1) staff as well as ninety five (5) residents. During the inspection, two (2) additional staff arrived and the mother of the Licensee. 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 proper signage throughout the facility, sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, PPE supplies are insufficient, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor resident(s) regularly for any changes in condition and to subsequently notify the resident(s) physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2022
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 04/18/2022 03:32 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 04/18/2022 at 03:17 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: NEW HOPE RESIDENTIAL ELDER CARE, LLC
FACILITY NUMBER: 336424391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation of the laundry room locked and a bottle of laundry detergent was on top of the counter and two cabinets with locks were left unlocked and a can of cleaning powder was observed with first aide items. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Licensee to agrees to conduct replace knob with a key lock knob and submit In-service on Supervision and Safety on Proof to be submitted to the Department by 5pm on 4/21/2022
Type A
Section Cited
CCR
81087(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation a cart covered in a blue towel was in the shower of the shared residents' bathroom and LPA had staff remove the towel and a pair of scissors were on top. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Licensee to agrees to conduct and submit In-service on Safety on locked sharps. Proof to be submitted to the Department by 5pm on POC 4/21/2022
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: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022


LIC809 (FAS) - (06/04)
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