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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606472
Report Date: 08/13/2020
Date Signed: 08/13/2020 03:52:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BANNER RIDGE COUNTRY HOMEFACILITY NUMBER:
197606472
ADMINISTRATOR:ELNA C. VILLAFLORFACILITY TYPE:
740
ADDRESS:1006 BANNER RIDGE ROADTELEPHONE:
(909) 240-1899
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 6DATE:
08/13/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Elna Villaflor (Administrator)TIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Kruz Long and Nicole Spencer conducted a Case Management visit in order to review the facilities compliance with Title 22 and the Order and Stipulation dated 02/02/2017. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today's Case Management visit was conducted via Zoom (Video Conferencing) with Elna Villaflor.

During today's video visit, LPAs toured the physical plan and requested copies of the facility records, staff records and resident records. During a video tour, LPAs observed that the physical plan was clean and in good repair. Smoke detectors/carbon monoxide detector are operable. Sufficient food supplies were observed. Disinfectants, cleaning solutions, poisons, and other items which could pose a danger is stored in the laundry room inaccessible to Residents. All bathrooms contain operable toilets, hand washing basins, non-skid mats and grab bars. Fire extinguisher in the kitchen is fully charged. Telephone system is a land line located in the kitchen. First aid kit is fully stocked and the first aid manuals are locked in the kitchen cabinet. Medications are also locked in the kitchen cabinet inaccessible to Residents. Alert system is operable on every exit door. All walkways and pathways are free of obstruction. Attached garage is used for storage. The linens are in good repair. Hygiene items of general use such as soap and toilet paper are available. Water temperature measured at 105 degree F in bathroom #1. Outdoor shaded area was observed. No deficiencies were observed during today's video visit.

A video exit interview was conducted with Elna Villaflor and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2020
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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