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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606472
Report Date: 01/12/2024
Date Signed: 01/12/2024 04:08:46 PM


Document Has Been Signed on 01/12/2024 04:08 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:ELNA C. VILLAFLORFACILITY TYPE:
740
ADDRESS:1006 BANNER RIDGE ROADTELEPHONE:
(909) 240-1899
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 4DATE:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Raquel Salen, StaffTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 1/12/24. LPA arrived unannounced and met with Staff, Raquel Salen. The purpose of the visit was explained. 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 1 resident.

LPA utilized the Compliance and Regulatory Enforcement (CARE) Tools to inspect the home. The following were observed:
Infection Control: The facility has submitted an Infection Control Plan. Staff are continuing to clean and disinfect the home. They are using appropriate hand hygiene and wearing gloves while assisting residents. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are no residents utilizing oxygen at this time. Facility has the required amount of liability insurance coverage.
Physical Plant & Environment Safety: The facility has 5 resident rooms, living room, dining area, family room, kitchen, 2 bathrooms, and 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.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The foods are properly stored in the refrigerator. The kitchen is kept clean and free of insects and vermin.

LPA will continue with the remainder of the domains at a later date. No deficiencies are issued today.
An exit interview was held and a copy of this report was given to the administrator.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
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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