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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425398
Report Date: 02/21/2025
Date Signed: 03/11/2025 02:00:55 PM

Document Has Been Signed on 03/11/2025 02:00 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:ANNA'S PARK HAVENFACILITY NUMBER:
336425398
ADMINISTRATOR/
DIRECTOR:		ANNA ESTANIELFACILITY TYPE:
740
ADDRESS:3911 PARK AVENUETELEPHONE:
(951) 658-6223
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 6CENSUS: 6DATE:
02/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Anna EstanielTIME VISIT/
INSPECTION COMPLETED:
04:00 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- Three (3) records were reviewed. LPA reviewed for admission agreement, medical assessment-1 expired and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records-1 missing, safeguard for personal property/valuables, and personal rights notification. This facility is not meeting documentation requirements.

Due to time constraints, LPA will need to return to complete the annual inspection. The following domains were completed: Res-Rec Incidental Reports, Incidental M&D, Resident SHN.



Based on the information received during this visit today, there are two (2) deficiencies is being cited per Title 22, Division 6 of The California Code of Regulations.

This report, LIC809D and Appeal Rights was reviewed with and a copy provided to the facility representative at the time of the exit interview.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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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Document Has Been Signed on 03/11/2025 02:00 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 02/21/2025 at 03:44 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: ANNA'S PARK HAVEN
FACILITY NUMBER: 336425398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(5)
Medical Assessment: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101, Definitions, or bedridden as defined in Health and Safety Code section 1569.72. The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in R1 did not have a current phyisican's report and primary diagnosis is Dementia in file poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
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Licensee will ensure that resident's LIC602 will be completed and obtain an current LIC602 for resident and email a copy to LPA by POC due date
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA Delgado's observation, interviewand record review, the licensee did not comply with the section cited above in Resident #2 PRN medications were not documented when dosage was taken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
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2
3
4
Licensee will conduct in-service training and provide copies of documentation for PRN medication to LPA 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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
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