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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606472
Report Date: 12/06/2024
Date Signed: 12/06/2024 05:47:05 PM

Document Has Been Signed on 12/06/2024 05:47 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BANNER RIDGE COUNTRY HOMEFACILITY NUMBER:
197606472
ADMINISTRATOR/
DIRECTOR:
ELNA C. VILLAFLORFACILITY TYPE:
740
ADDRESS:1006 BANNER RIDGE ROADTELEPHONE:
(909) 240-1899
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Raquel Salen, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection on 12/6/24. LPA met with Staff, Raquel Salen, and explained the purpose for the visit. Administrator, Elna Villaflor, arrived to assist with the visit. The facility is licensed to serve (6) non-ambulatory residents, ages 60 and over. There is an approved hospice waiver for 6 residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) Tools to inspect the home.
The facility has 5 resident bedrooms, 2 bathrooms, living room, 2 dining areas, family room, kitchen, laundry room, and an attached garage. The hot water temperature was measured between the required range of 105-120 degrees F. There are no swimming pool or bodies of water on the premises. The fireplace is adequately screened. There are smoke detectors located in each bedroom and a carbon monoxide detector located in the hallway. Disinfectant, cleaning solutions, knives are locked and inaccessible to residents. There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The kitchen is kept clean and free of insects and vermin. The facility accepts and retains residents with dementia. There are no residents utilizing oxygen at this time. Facility has the required amount of liability insurance. Facility staff are continuing to follow the Infection Control Plan and using appropriate hand hygiene while providing care. Per the licensee, there is sufficient staffing at the facility. Staff employed have fingerprint clearance and associated to the facility. LPA reviewed 3 staff files and files have current CPR & first aid certificate. Resident files are maintained at the facility and have the following documents in their files. Medications were reviewed for all 5 residents and no discrepancies were observed. The Complaint poster, Local Ombudsman, and Residents personal rights are posted. Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability. The facility has an Emergency Disaster Plan easily accessible with contact numbers and at least 2 relocation sites. Facility conducts disaster drills.

No deficiencies were issued today. An exit interview was held. A copy of this report was given to E.Villaflor.
Tony VasalloTELEPHONE: (323) 981-3977
Cynthia D ChanTELEPHONE: (323) 981-3370
DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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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