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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911501
Report Date: 12/07/2023
Date Signed: 12/07/2023 04:05:06 PM


Document Has Been Signed on 12/07/2023 04:05 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:WARBLER RCFEFACILITY NUMBER:
330911501
ADMINISTRATOR:EMMANUEL MANALADFACILITY TYPE:
740
ADDRESS:11661 WARBLER WAYTELEPHONE:
(951) 924-9179
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:6CENSUS: 3DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:54 PM
MET WITH:Staff, Cornelia ManaladTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Staff, Cornelia Manalad, who was informed of the purpose of the visit. At time of visit there were (3) clients and one (2) staff present.

The facility is a two story home with five (5) bedrooms and (3) bathrooms with attached garage. All resident rooms are located on the first floor. The facility does not have a pool or fire arms are kept at the facility. The facility is residential care facility for the elderly vendorized through Inland Regional Center. The residents served are elderly ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Infection Control: LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility.

Physical Plant: LPA observed the client bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards and contained outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 112F.

Food Service: LPA observed 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.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WARBLER RCFE
FACILITY NUMBER: 330911501
VISIT DATE: 12/07/2023
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Record Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in hallway closet. LPA reviewed client medications for (1) client and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA documented technical note for licensee to update the plan to new LIC610D. LPA reviewed documentation showing last fire drill conducted 12/2/23. LPA observed all facility exits were clear from obstructions.

No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Staff, Cornelia Manalad.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
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