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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427427
Report Date: 05/13/2022
Date Signed: 05/13/2022 02:53:23 PM

Document Has Been Signed on 05/13/2022 02:53 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 II LLCFACILITY NUMBER:
336427427
ADMINISTRATOR:MIKENAS, ANNIE JANEFACILITY TYPE:
740
ADDRESS:30221 POWDERHORN LANETELEPHONE:
(951) 467-0330
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 6CENSUS: 5DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Licensee- Annie Jane MikenasTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by S1, and met with Licensee Annie Jane Mikenas who was informed of the purpose of the visit. At the time of visit there was 3 staff and 5 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings at the facility. A single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. LPA advised Licensee to document temperatures for staff, visitor and residents. This will be documented on an LIC9102TA. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all restrooms. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA observed a sufficient 30-day supply of PPE equipment. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II LLC
FACILITY NUMBER: 336427427
VISIT DATE: 05/13/2022
NARRATIVE
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LPA was provided with a copy of the facility Mitigation plan and Licensee will submit this to the department by 5/16/2022 5:00pm.

During the tour of the facility LPA and Licensee observed the following deficiencies:
· LPA requested a current resident roster LIC9020. The facility did not have a resident roster. LPA was given a typed up list of residents that was outdated with 2 residents (R1 and R2) that had expired. LPA also noticed R3 who had passed away “a couple weeks ago” per S1 was not on the typed sheet.

· LPA observed PRN medication in the refrigerator that was not locked in the designated lock box.

· LPA reviewed SIR log and noticed the last SIR was dated in 2017. LPA inquired with Licensee about SIR’s including death reports for R1, R2 and R3. Licensee was able to show proof of SIR's submitted for R2 and R3 but not for R1 who had expired more than 7 days ago.

· LPA observed observed S2 and S3 on LIC500 who were not associated to the facility. S2 is cleared but not associated and worked at the facility per Licensee. This a zero tolerance related regulation. Licensee will receive a civil penalty of $500. S2 does not posses a background clearance and is listed as a staff member on LIC500. For this Licensee will be issued a civil penalty of $500. Civil penalties will total $1000.

An exit interview was conducted, a copy of this report, and appeal rights were provided to facility licensee, Annie Jane Mekinas.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2022 02:53 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/13/2022 at 01:58 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 II LLC
FACILITY NUMBER: 336427427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record review, the licensee did not comply with the section cited above with staff member that was not associated to the facility and was listed on the LIC500. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Licensee will submit an updated copy of LIC500 by POC date.
Type A
Section Cited
HSC
80019(e)(2)


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 with staff member that was not associated to the home but on the LIC500. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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LIcensee will submit updated LIC500 to LPA.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2022 02:53 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/13/2022 at 02:10 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 II LLC
FACILITY NUMBER: 336427427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above with 4 PRN medication that were being kept in the refrigerator unlocked. This poses a potential health and safety to residents in care.
POC Due Date: 05/23/2022
Plan of Correction
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Licensee will submit proof of PRN medication being kept in a locked cabinet.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
3
4
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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2022 02:53 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/13/2022 at 02:15 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 II LLC
FACILITY NUMBER: 336427427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87508(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having an LIC9020 on file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2022
Plan of Correction
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Licensee will submit proof of LIC9020 to LPA by POC date.
Type B
Section Cited
CCR
80061(b)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by not deporting the death of a resident R1. The death has pased the 7 days reporting requirment. This poses a potential health and safety risk to persons in care..
POC Due Date: 05/23/2022
Plan of Correction
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Licensee will submit death report to the department by POC 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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


LIC809 (FAS) - (06/04)
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