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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425652
Report Date: 02/21/2025
Date Signed: 02/21/2025 02:17:54 PM

Document Has Been Signed on 02/21/2025 02:17 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GENEROUS HOMECAREFACILITY NUMBER:
336425652
ADMINISTRATOR/
DIRECTOR:		M LIBED/G LIBEDFACILITY TYPE:
740
ADDRESS:31729 BOTTLE BRUSH ST.TELEPHONE:
(619) 398-6785
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 6CENSUS: 2DATE:
02/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:34 AM
MET WITH:Licensee/Administrator-Mary LibedTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 02/21/2025 at 9:34 AM, Licensing Program Analysts (LPAs) Melody Brown and Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown and LPA Singh met with Licensee/administrator Mary Libed and was granted entry to the facility. At the time of the visit there were two (2) staff present, and two (2) residents present. LPA Brown and LPA Singh explained the purpose of the visit to Licensee/Administrator Mary Libed.

The facility has 7 bedrooms, in which 5 bedrooms are designated for residents, and 2 bedrooms are designated for staff/family, 2 and 1/2 bathrooms, living room, kitchen, dining area, backyard, and attached garage. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents, the current census is two (2) residents. The facility has approved hospice waiver for three (3) residents. LPA Singh was accompanied by Licensee/Administrator to conduct a general overall inspection, which included, but was not limited to, the following:


Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). The buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. The facility is maintained at a comfortable temperature of 75 degrees F.. LPAs inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. During the tour of the facility, LPAs observed one window and one door screen in disrepair. Technical violation issued. Also, LPAs observed No night lights maintained in hallways and passageways to non-private bathrooms. Deficiency will be issued.

***Continuation on LIC 809C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GENEROUS HOMECARE
FACILITY NUMBER: 336425652
VISIT DATE: 02/21/2025
NARRATIVE
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LPA Singh measured and observed the water temperature in the residents/staffs shared bathroom to be at 125 degrees F and second bathroom 122 degrees F. Deficiency will be issued.
The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCLD complaint poster, ombudsman poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care.

There was a designated storage space for resident/staff files. Medications are kept inside the medication closet in the hallway inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility. No Emergency food and emergency supplies. Deficiency will be issued.

Care & Supervision: LPAs observed that the facility does not have a staff scheduled to work the night shift, awake and on duty as required for facility with Dementia residents as determined on residents medical assessment/Physician Report (LIC602). Deficiency will be issued.

Record Review: LPA reviewed two (2) resident files for admission agreements, updated physician reports, pre-placement appraisals, needs and services plans. The files were complete with updated physician’s reports, admissions agreements. However, pre-admissions appraisals was not completed for Resident#1(R1) and Resident#2(R2). Deficiency will be issued.

LPAs reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results.

***Continuation in LIC809C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
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
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GENEROUS HOMECARE
FACILITY NUMBER: 336425652
VISIT DATE: 02/21/2025
NARRATIVE
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Medications/MARs records were audited and appeared to be dispensed and logged appropriately.

Also, LPAs observed facility emergency plan not reviewed, not updated annually, signed and dated. As evidence of disaster plan posted has signature date of 5/27/2021. Deficiency will be issued.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.


An exit interview was conducted, and this report (LIC809), LIC809C, LIC 809D and Appeal Rights were discussed and provided to Licensee/Administrator Mary Libed.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
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
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 02/21/2025 02:17 PM - It Cannot Be Edited


Created By: Beena Singh On 02/21/2025 at 12:54 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: GENEROUS HOMECARE
FACILITY NUMBER: 336425652

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not ensuring that Residents bathroom #1 were delivering hot water as required to attain temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2025
Plan of Correction
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Licensee stated to regulate the hot water temperature in residents shared bathrooms to attain temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C) and submit proof to LPA Singh by the plan of correction (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:Efren Malagon
LICENSING EVALUATOR NAME:Beena Singh
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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Document Has Been Signed on 02/21/2025 02:17 PM - It Cannot Be Edited


Created By: Beena Singh On 02/21/2025 at 12:54 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: GENEROUS HOMECARE
FACILITY NUMBER: 336425652

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview], the licensee did not comply with the section cited above by not ensuring that night lights are maintained in hallways and passageways to non private bathrooms, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Licensee stated to obtain or purchase night lights and submit proof to LPA singh by the Plan of correction(POC) due date.
Type B
Section Cited
CCR
87457(c)(1)(B)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall document, at a minimum: (B) Whether the prospective resident’s or other residents’ safety would be at risk if the prospective resident is allowed access to any of the items specified in Section 87307, Personal Accommodations and Services and in Section 87309, Storage Space and Access.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above by not completing the required pre-placemnt appraisal for two (2) of two(2) residents, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Licensee stated to submit R#1 R#2 pre-placement appraisal to LPA singh by the 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:Efren Malagon
LICENSING EVALUATOR NAME:Beena Singh
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)
Page: 5 of 8
Document Has Been Signed on 02/21/2025 02:17 PM - It Cannot Be Edited


Created By: Beena Singh On 02/21/2025 at 12:54 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: GENEROUS HOMECARE
FACILITY NUMBER: 336425652

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having the required emergency food and emergency supplies which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Licensee stated to obtain or purchase emergency food and supplies and submit proof to LPA Singh by the Plan of correction(POC) due date.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review], the licensee did not comply with the section cited above by not updating, reviwed and signed the emergency disaster plan, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Licensee stated to update,review and sign the emergency disaster plan and submit proof to LPA Singh by the 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:Efren Malagon
LICENSING EVALUATOR NAME:Beena Singh
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)
Page: 6 of 8
Document Has Been Signed on 02/21/2025 02:17 PM - It Cannot Be Edited


Created By: Beena Singh On 02/21/2025 at 01:49 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: GENEROUS HOMECARE
FACILITY NUMBER: 336425652

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(b)(2)
87705 Care of Persons with Dementia (b) Licensee shall be responsible for the folowing: (2) For facilities with fewer than 16 residents, ensuring there is at least one night staff person awake and on duty...

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 there is a staff schedule to work at night, awake and on duty as required,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2025
Plan of Correction
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Licensee stated to submit an updated a personnel report (LIC500) or updated staff schdule that will show a staff schedule to work the night shift, awake and on duty to LPA Singh by the Plan of correction (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:Efren Malagon
LICENSING EVALUATOR NAME:Beena Singh
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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