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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603665
Report Date: 07/26/2024
Date Signed: 07/26/2024 03:36:48 PM

Document Has Been Signed on 07/26/2024 03:36 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:DEVON PLACE HOME CAREFACILITY NUMBER:
374603665
ADMINISTRATOR/
DIRECTOR:		MARK LOOFACILITY TYPE:
740
ADDRESS:1814 DEVON PLACETELEPHONE:
(760) 941-1818
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 6CENSUS: 6DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Edmund De La Calzada - CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with caregiver Edmund De La Calzada, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and six (6) residents present. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

LPA observed a three (3) inch oval shaped hole in the floor near the dining room area. A deficiency will be issued under Title 22 Regulation 87303(a). Washer and dryer is located outside in the backyard. LPA observed laundry detergent and bleach out and inaccessible to residents in care. Kitchen cabinet under the sink was unlocked and had bug spray and cleaning solutions accessible to residents in care. A deficiency will be issued under Title 22 regulation 87309(a). Sharp objects in a kitchen drawer was unlocked and accessible to residents diagnosed with dementia in care. A deficiency will be issued under Title 22 regulation 87705(f)(1).The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.



LPA reviewed three (3) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid. LPA was informed Staff Two (S2) was not fingerprint cleared and had assisted Staff One (S1) for the day due to a staff call off. A deficiency and civil penalty will be issued under Title 22 Regulation 87355(e). S2 was informed they had to leave the facility and could not continue to provide care and supervision to the residents in care. Six (6) resident files were reviewed. Resident One (R1), Resident Two (R2), and Resident Three (R3) did not have a resident pre-appraisal in their file for review during the visit. A deficiency will be issued under Title 22 Regulation 87457(c). Resident Two (R2), Resident Three (R3), Resident Four (R4), and Resident Five (R5) who are diagnosed with Dementia did not have an updated LIC 602 Physician's Orders during LPA's visit.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 07/26/2024 03:36 PM - It Cannot Be Edited


Created By: Sara Martinez On 07/26/2024 at 01:45 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: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having one (1) individual (S1) working at the facility providing care and supervision to residents in care without having fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2024
Plan of Correction
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Licensee will ensure all staff members working at the facility who provides care and supervision to residents in care will have fingerprint clearance prior to working. S1 must be fingerprint cleared prior to returning back to the facility.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 07/26/2024 03:36 PM - It Cannot Be Edited


Created By: Sara Martinez On 07/26/2024 at 01:45 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: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 having disinfectants and cleaning solutions accessible to residents in care. Cabinet under the sink was unlocked which contained disinfectants and bug spray which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will ensure disinfectants, cleaning solutions, poisons, and other items which could pose a danger to residents in care are inaccessible at all times. Licensee will conduct in-service staff training regarding this regulation and will send training materials and staff sign-in sheet to LPA by plan of correction date 08/02/2024.
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (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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Based on observation, interview, and record review, the licensee did not comply with the section cited above for R1 and R2 having dispensed PRN medication without documenting either time and/or date the dosage was taken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will ensure PRN medication assistance for all residents in care will be documented following the regulation listed above by staff. Licensee will conduct in-service staff training with staff regarding this regulation and will provide LPA with the training materials provided to staff and staff sign-in sheet by plan of correction date 08/02/2024.
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:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 07/26/2024 03:36 PM - It Cannot Be Edited


Created By: Sara Martinez On 07/26/2024 at 01:45 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: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
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 his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

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 in having pre-admission appraisal available for records review for Resident One (R1), Resident Two (R2), and Resident Three (R3) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will ensure all residents who are currently admitted or will be admitted to this facility have the resident pre-admission appraisal completed to determine resident's needs and services. Licensee will submit Resident Appraisal to LPA for R1, R2, and R3 by plan of correction date 08/02/2024.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in conducting a quarterly disaster drill with staff for each shift which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will ensure quarterly disaster drills will be conducted with staff to ensure the safety of the residents in care. Licensee will submit disaster drill training materials and staff sign in sheet for each shift to LPA by the plan of correction date 08/02/2024.
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:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 07/26/2024 03:36 PM - It Cannot Be Edited


Created By: Sara Martinez On 07/26/2024 at 01:45 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: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(1)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, the licensee did not comply with the section cited above in having an updated roster with the current residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will ensure a resident roster will be updated as needed and readily available to facility staff during an emergency. Licensee will submit updated resident roster to LPA by plan of correction date 08/02/2024.
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 having sharp objects and scissors in a unlocked kitchen drawer which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will ensure sharp objects and other items that could pose a danger to resident in care are inaccessible at all times. Licensee will conduct in-service staff training regarding this regulation and will send training materials and staff sign-in sheet to LPA by plan of correction date 08/02/2024.
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:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 07/26/2024 03:36 PM - It Cannot Be Edited


Created By: Sara Martinez On 07/26/2024 at 02:21 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: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(i)
87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident...
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having expired medication prescribed to Resident six (R6) marked as "Back-up meds" with a use before date of 10/01/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will ensure all medication will be discarded and destroyed by the facility as ordered by resident's physician and documented in centrally stored medication record. Licensee will conduct in-service training with staff and provide LPA with training materials and staff sign in sheet by plan of correction date 08/02/2024.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 having a three (3) inch oval hole in the floor near the dining room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will ensure facility is in good repair at all times for residents, employees, and visitors at all times. Licensee will submit a plan to LPA on how they will fix the damaged floor near the dining room kitchen by plan of correction date 08/02/2024.
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:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 07/26/2024 03:36 PM - It Cannot Be Edited


Created By: Sara Martinez On 07/26/2024 at 02:46 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: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia: (c) Licensees...shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually... This requirement was not met by:

Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in having an annual medical assessment conducted for Resident Two (R2), Resident Three (R3), Resident Four (R4), and Resident Five (R5) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will ensure residents with a diagnosis of Dementia will have a annual medical assessment conducted and documented to ensure the appropriate needs and services of the residents are being met. Licensee will submit updated LIC 602 to LPA by the plan of correction date 08/02/2024.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


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: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665
VISIT DATE: 07/26/2024
NARRATIVE
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 A deficiency will be issued under Title 22 Regulation 87705(c)(5). Resident medication was centrally stored and locked in a cabinet located in the dining room. LPA observed PRN medication for Resident One (R1) and R2 administered to residents by staff without documenting the date and/or time PRN was given to the resident. A deficiency will be issued under Title 22 regulation 87465(d)(3). LPA observed medication prescribed to Resident Six (R6) in a ziplock back with "back-up meds" written in sharpie. R6's medication had a "use before" date of 10/01/2022. A deficiency will be issued under Title 22 Regulation 87465(i). LPA reviewed the facility's emergency and disaster plan. Facility does not have an updated resident roster for staff readily available in preparations for an emergency. A deficiency will be issued under Health and Safety Code 1569.695(e)(1). Facility has not conducted and documented a quarterly disaster drill with staff from each shift. A deficiency will be issued under Health and Safety Code 1569.695(c).

An exit interview was conducted where a copy of this report, deficiency page(s) LIC 809-D, Confidential Names LIC 811, Civil Penalty, and Appeal rights were provide to caregiver Calzada.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC809 (FAS) - (06/04)
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