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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424391
Report Date: 02/05/2025
Date Signed: 02/05/2025 03:42:27 PM

Document Has Been Signed on 02/05/2025 03:42 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:NEW HOPE RESIDENTIAL ELDER CARE, LLCFACILITY NUMBER:
336424391
ADMINISTRATOR/
DIRECTOR:		ANNIE JANE MIKENASFACILITY TYPE:
740
ADDRESS:39520 BONAIRE WAYTELEPHONE:
(951) 600-2941
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 5CENSUS: 4DATE:
02/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Edward MikenasTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection. The LPA was greeted by Administrator Edward Mikenas, notified him of the purpose for the visit and was allowed to enter the facility to conduct the inspection.

Facility Overview: The facility is a two story building (Approved to only use the lower level) with four (4) residents bedrooms, two(2) bathrooms, a living room, a kitchen area, a garage and two sheds. There is no gated pool and there are no firearms on the premises.

Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen inaccessible to residents. The smoke detector and carbon monoxide detector were operational. LPA observed fire extinguishers to be in compliance with the department requirements with an expiration date of January 27th, 2026. The water temperature was tested within regulations.

Continued 809-C......

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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: NEW HOPE RESIDENTIAL ELDER CARE, LLC
FACILITY NUMBER: 336424391
VISIT DATE: 02/05/2025
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Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of July 01, 2025


Record Review and Resident/Staff Files: LPAs reviewed files for two(2) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. LPA observed that the staff did not have the health screening in their folder. A citation will be issued. Four (4) residents' files were reviewed. LPA observed one of four residents' file not to have an updated physician report. A citation will be issued.

Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the living room. LPA reviewed medications for four residents, confirming that all medications were listed and accounted for.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including records of the last drill conducted at the facility on November 2024. LPA observed the exist door by the front entrance to be obstructed by a built in bird cage. A citation will be issued


An exit interview was conducted, during which this report was reviewed, and a copy was provided to Administrator Edward Mikenas along with the appeal rights.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
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Document Has Been Signed on 02/05/2025 03:42 PM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 02/05/2025 at 01:36 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: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
87203
FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshall for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:


Deficient Practice Statement
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Based observation and interview, the licensee did not comply with the section cited above in one exit door to be obstructed by a built in bird cage which poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2025
Plan of Correction
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LIcensee will remove the birds and put them in another cage located in the backyard and clean all debris by the exit door. Licensee will send pictures of correction by POC due date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia (c) Licensse who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in section 87458, medical assessment...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview, record review, the licensee did not comply with the section cited above by not ensuring that resident #1 (R1) has the required annual medical assessment as R1s medical asessment date is 03/03/2023 which poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2025
Plan of Correction
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Licensee stated to obtain a medical appointment for R1 to complete the required annual medical assessment and submit proof to LPA Abdoulaye by the plan of correction (POC) due date.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/05/2025 03:42 PM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 02/05/2025 at 02:40 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: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
87411(f)
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based observation and interview, the licensee did not comply with the section cited above in two staff files observed to be missing health screening, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2025
Plan of Correction
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Licensee will send proof of correction by POC due date

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:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


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