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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426228
Report Date: 11/20/2024
Date Signed: 11/20/2024 03:47:15 PM

Document Has Been Signed on 11/20/2024 03:47 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:ARIA BOARD AND CAREFACILITY NUMBER:
336426228
ADMINISTRATOR/
DIRECTOR:		MEZA, WALTERFACILITY TYPE:
740
ADDRESS:913 ARIA RD.TELEPHONE:
9513572025
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 6CENSUS: 6DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Meza WalterTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 11/20/2024, Licensing Program Analyst (LPA) Abdoulaye Zerbo made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection LPA Abdoulaye met with Licensee/Administrator Meza Walter and was granted entry to the facility. At the time of the visit there was one (1) staff present, and Six (6) residents present.

The facility is a five (5) bedrooms, three (3) bathroom home with a kitchen/dining area, living room/activity room and a garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory and six (6) hospice care and 1 maybe bedridden resident and the current census is six (6) residents. LPA Zerbo was accompanied by administrator Meza 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). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA Abdoulaye 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. LPA observed sufficient furniture and lighting throughout the facility. LPA Zerbo measured and observed the water temperatures in several bathrooms averaging 110.6 degrees. The facility is equipped with operating smoke detectors and one carbon monoxide was not working. A citation will be issued. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, 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 in the kitchen area. There is a Medicine cabinet with the resident’s medications locked in the kitchen area. LPA Zerbo observed a complete first aid kit at the facility.

***Continuation in LIC809C ***

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ARIA BOARD AND CARE
FACILITY NUMBER: 336426228
VISIT DATE: 11/20/2024
NARRATIVE
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Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has an Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Also, LPA Zerbo observed that the facility currently does not have dementia residents.

Record Review: LPA reviewed five (5) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Zerbo observed resident files reviewed were complete. LPA Zerbo reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA Zerbo observed resident files reviewed were. LPA observed that licensee did not complete drill quarterly. A citation will be issued

An exit interview was conducted and a copy of this report along with the appeal rights were reviewed and a copy was provided to Licensee/Administrator Meza Walter

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/20/2024 03:47 PM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 11/20/2024 at 02:31 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: ARIA BOARD AND CARE
FACILITY NUMBER: 336426228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2024
Section Cited

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1503.2 CARBON MONOXIDE DETECTORS REQUIRED; INSPECTION. Every facility licensed shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12.
This requirement is not met
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Based on observation, the licensee failed to ensure facility was equipped with one(1) of two(2) working carbon monoxide to meet the standards.
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/20/2024 03:47 PM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 11/20/2024 at 03:08 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: ARIA BOARD AND CARE
FACILITY NUMBER: 336426228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2024
Section Cited

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(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
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Based on interview and record review, the licensee did not comply with the section cited above with last fire drill conducted July 2024. This poses a potential health, safety or personal rights risk to persons in care.
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
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