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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800091
Report Date: 06/05/2024
Date Signed: 06/05/2024 03:38:08 PM


Document Has Been Signed on 06/05/2024 03:38 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:MONUMENT PARK MANORFACILITY NUMBER:
331800091
ADMINISTRATOR:G. CABANA & C. MAGISTRADOFACILITY TYPE:
740
ADDRESS:175 MUIR WOODS ROADTELEPHONE:
(951) 943-6403
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY:6CENSUS: 3DATE:
06/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Carlos Magistrado, AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility for the purpose of conducting a 1 year required visit/annual inspection. LPA George met with and informed Administrator's Genefer Gabana and Carlos Magistrado and informed them of the purpose day's visit. At the time of the visit there were two (2) staff and two (2) residents present. Below is a summary of what was observed during today’s inspection:

Physical Plant: LPA toured the interior and exterior of the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. The facility was observed to have the required furniture and linen to be present and in good condition inside the occupied resident bedrooms. The exits are free from obstruction. The facility was observed to have operable flashlights. There are no pools or bodies of water on the premises. There is a shaded patio, for the residents to enjoy and to promote socialization.

Staff Records Review: LPA observed that there are sufficient staff present to meet the needs of residents. LPA George additionally confirmed that there is an Administrator present. LPA George confirmed staff have criminal record clearance and were associated to the facility and have training to perform their required duties. Staff present were observed have current CPR/First Aid Certification.

Resident Records Review: A review of all three (3) files was conducted and revealed that the files have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. There is one resident where the 602 was requested, but has not been received. Administrator will follow up on the request.



Food Services: The kitchen and dining area to be maintained in a clean and healthful manner. LPA George observed the facility to have the required amount of 7 day supply non-perishable and a two supply perishable food items. The facility was observed to have five (5) recently (6/1/24) expired canned goods that were discarded at the time of LPAs visit, therefore no citation issued.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024
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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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: MONUMENT PARK MANOR
FACILITY NUMBER: 331800091
VISIT DATE: 06/05/2024
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Medication: Resident medication was observed to be stored in a locked cabinet leading to the hallway. The medication were inaccessible to residents. A review of medication revealed that the medication is being given as prescribed as evidenced by the Medication Authorization Record (MAR) and medication (bubble packs and or pill bottle).

Disaster Preparedness: The facility has an Emergency Disaster Plan on file. The last emergency disaster drill was conducted on 5/29/24 .The smoke and carbon monoxide detectors were tested and were found to be operable. The facility was observed to have a fully charged fire extinguisher.

There is a total of four (4) firearms on the premises that is locked in a DOJ gun locker . Per Administrator Carlos there is no ammunition here at the facility. Note that LPA did not observe any ammunition, inside the locker. The gun locker is stored in a locked/secured area. The hot water was tested and was found to be within regulatory limit measuring at 109.7-113.3 degrees Fahrenheit. The sharps and hazardous chemicals were observed to be locked and inaccessible to residents in care.

Based on today's inspection there were no deficiencies cited.

An exit interview was conducted and a copy of this report, were provided to Administrator's Genefer Gabana and Carlos Magistrado.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
LIC809 (FAS) - (06/04)
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