330909355-9-18-2023-56-AS-MRIO-CVSRXE-20230918132436

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 330909355
Report Date: 09/18/2023
Date Signed: 09/18/2023 01:24:42 PM

Document Has Been Signed on 09/18/2023 01:24 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	PEPPERMINT RIDGE - CYPRESS POINT		FACILITY NUMBER:	330909355
ADMINISTRATOR:	TERRAY DOTY		FACILITY TYPE:	735
ADDRESS:	632 MAGNOLIA AVENUE		TELEPHONE:	(951) 273-7342
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY:	6	CENSUS: 5	DATE:	09/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:23 PM
MET WITH:	Terray Doty		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA was granted entry to the facility. The facility is a five (5) bedroom, two (2), bathroom home and, with a kitchen/dining area, living room and attached garage. The facility is an Adult Residential Facility (ARF) level 2 vendor by Inland Regional Center. Licensed capacity is (6) current census (5). LPA was accompanied by Terray Doty do to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. All sharps are locked. The hot water temperature tested within regulation at 114 degrees. There was a designated space for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed three (3) client medications. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PEPPERMINT RIDGE - CYPRESS POINT	FACILITY NUMBER: 330909355
	VISIT DATE: 09/18/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provide to Terray Doty.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

LIC809 (FAS) - (06/04)

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