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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881428
Report Date: 09/09/2024
Date Signed: 09/09/2024 03:17:52 PM

Document Has Been Signed on 09/09/2024 03:17 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MOTHER DOLOROSA HOME CAREFACILITY NUMBER:
371881428
ADMINISTRATOR/
DIRECTOR:		RAMIREZ, JOSE RICARDO L.FACILITY TYPE:
740
ADDRESS:29533 MACTAN ROADTELEPHONE:
(858) 610-4098
CITY:VALLEY CENTERSTATE: CAZIP CODE:
92082
CAPACITY: 6CENSUS: 4DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Raymond Ramirez, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 09/09/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit annual inspection. LPA was greeted and granted entry by Caregiver Diosdado Delena where LPA explained the purpose of the visit. At the time of the visit there was (1) staff and (4) residents present. LPA conducted a tour of the interior and exterior and observed the following:

The facility is in need of overall cleaning as there were trails of ants crawling in the dining room area, cob webs with spiders both alive an unalived on the walls and floor, multiple flies flying around and sitting on the kitchen table, the smell of urine, in addition there was dried puddles of urine on Resident #1 (R1) bedroom floor. Deficiency cited. In the kitchen LPA observed for the refrigerator to have a red magnetic lock. The facility does not have an approved waiver on file to have a lock on the refrigerator. Per the administrator the purpose is to minimize the residents from increasing their sugar intake. Per the file review there was no Doctor that had prescribed any of the residents with a specialized diet. Deficiency cited. LPA conducted a review of contact information and observed for the facility to not have a telephone on the premises. Deficiency cited.

The medications are stored in a locked cabinet, that is stored in the hallway heading to the kitchen. LPA observed for the medications being stored in weekly increments, rather than in the original packaging. Deficiency cited. There are no known guns or ammunition, or pools or bodies of water on the premises.
LPA conducted a file review on both staff and resident files. The administrator Raymond Ramirez, Administrator certification expired on 07/29/24, however proof of renewal was provided. The resident files were observed to have medical assessments and appraisals. The smoke and carbon monoxide detectors were tested and were found to be operable. The facility is conducting drills on a quarterly basis, the last drill was conducted on 7/31/24.Based on today's inspection citation's will be issued on the attached 809D, in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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: MOTHER DOLOROSA HOME CARE
FACILITY NUMBER: 371881428
VISIT DATE: 09/09/2024
NARRATIVE
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An exit interview was conducted and a copy of this report, 809D, LIC 9098 Proof of Corrections form, appeal rights and LIC811-Confidential names list was provided to Raymond Ramirez, Administrator.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 09/09/2024 03:17 PM - It Cannot Be Edited


Created By: Javina George On 09/09/2024 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: MOTHER DOLOROSA HOME CARE
FACILITY NUMBER: 371881428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87311
Telephones
All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews the licensee did not comply with the section cited above in 1 out of 1 time which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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The licensee agrees to install a landline in the home.
Proof of POC is to be submitted to the department by 5pm on the due date indicated.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 in 4 out of 4 times which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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The licensee agrees to begin storing the medications in the original containers received. A self certification statement will be submitted by both Licensee's and Administrator, on agreeing to implement and follow the regulation cited above
Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/09/2024 03:17 PM - It Cannot Be Edited


Created By: Javina George On 09/09/2024 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: MOTHER DOLOROSA HOME CARE
FACILITY NUMBER: 371881428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of the odor of urine in the facility the licensee did not comply with the section cited above in 1 out of 1 times which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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The Licensee agrees to increase check in R1s room, and clean the room and empty the commode at minimum 3 times a day. The administrator agreed to create and track via a log to document the facility's compliance.
Proof of POC is to be submitted to the department by 5pm on the due date indicated.
Type B
Section Cited
CCR
87468.1
87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. 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 by placing locks on the refrigerator without approved waiver. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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The lock was removed during LPAs visit. Administrator will discuss with staff to not put the lock on the refrigerator, staff will sign a form indicating that the statement is true and correct. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
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