331800091-6-15-2022-18-AS-CNWE-CFERCN-20220615125436

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800091
Report Date: 06/15/2022
Date Signed: 06/15/2022 12:54:42 PM

Document Has Been Signed on 06/15/2022 12:54 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MONUMENT PARK MANOR		FACILITY NUMBER:	331800091
ADMINISTRATOR:	G. CABANA & C. MAGISTRADO		FACILITY TYPE:	740
ADDRESS:	175 MUIR WOODS ROAD		TELEPHONE:	(951) 943-6403
CITY:	PERRIS	STATE: CA	ZIP CODE:	92570
CAPACITY:	6	CENSUS: 4	DATE:	06/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Carlos Magistrado, Licensee		TIME COMPLETED:	01:00 PM

NARRATIVE

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Licensing Program Analyst (LPA), Chinwe Nwogene made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by caregiver, Loreto Baguio who was informed of the purpose of the visit. Loreto called Licensee Carlos Magistrado who arrived to the facility shortly. At the time of visit there was 1 staff and 4 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, and hand sanitizer) in all restrooms (3 restrooms). The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be any event of COVID-19 related illnesses. The facility has a designated infection control lead. The facility also cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies. LPA did not observe any pools or bodies of water within the premises. LPA was informed that guns are maintained at the home, LPA observed guns are adequately secured in a locked safe in a locked closet. No annual fees due.

LPA also observed Licensee’s aunt present without the proper clearance. Loreto reported that Licensee’s aunt stayed in the facility overnight. Licensee was interviewed and he stated that his aunt was just visiting. LPA observed Licensee’s aunt departed the facility without issue.

One (1) deficiency and one (1) civil penalty will be cited per Title 22, Division 6, of the California Code or Regulations.

An exit interview was conducted, and a copy of this report was reviewed and provided to Carlos Magistrado.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022

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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Document Has Been Signed on 06/15/2022 12:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MONUMENT PARK MANOR	FACILITY NUMBER: 331800091
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(d)

Criminal Record Clearance

(d) All individuals subject to a criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/24/2022
	Plan of Correction
1 2 3 4	Carlos agreed the facility will submit a written statement of understanding of the regulation cited by POC due date 6/24/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022

LIC809 (FAS) - (06/04)

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