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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800091
Report Date: 06/23/2023
Date Signed: 06/29/2023 11:11:08 AM


Document Has Been Signed on 06/29/2023 11:11 AM - 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 AC/SC, 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:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Caregiver Noel GonzalesTIME COMPLETED:
12:30 PM
NARRATIVE
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On 6/23/2023, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced annual required visit to the facility at 10:00 a.m. LPA was greeted and granted entry by Caregiver Noel Gonzales who was informed of the purpose of the visit. During the visit, there was three (3) residents, and two (2) staff present.

The facility is made up of a one-story home with four (4) resident bedrooms, two (2) resident bathrooms, family room, dining area, kitchen, and an attached garage. LPA conducted a tour of the interior and exterior, and reviewed some facility documents. LPA observed the following:

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Both bathrooms have a working toilet, wash basin, and were equipped with a grab bar and non-slip mats in the shower. The facility has clean towels, blankets, and linen, available in different colors for each client.

Kitchen: LPA observed a sufficient supply of dishes, glasses, utensils, pots, and pans. The stove is operational. Refrigerator and freezer were in working condition. LPA observed sufficient perishable and non-perishable food available for the residents.

Laundry: Laundry area had a washer and dryer.

Continued on LIC809-C..
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 06/29/2023 11:11 AM - 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
RIVERSIDE AC/SC, 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: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by leaving disinfectants and cleaning solutions unsecured and accessible, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Facility agreed to conduct staff training regarding maintaining disinfectants, cleaning solutions and poisons, secured and locked, to ensure they are stored inaccessible to residents in care. Proof of correction will be submitted to CCLD by close of business on 6/30/2023.
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in by having a broken magnetic lock on the kitchen drawer that is used to store knives, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Facility agreed to repair/replace magnetic lock and properly secure knives to make them inaccessible to residents in care. Proof of correction to be submitted to CCLD by close of business on 6/30/2023.
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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2023 11:11 AM - 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
RIVERSIDE AC/SC, 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: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
87412 Personnel Records
(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview, the licensee did not comply with the section cited above due to Administrator possessing the personnel records file cabinet key on their person, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Facility agreed to maintain personnel records file cabinet key on the premises and provide proof to CCLD of the return of the key on 6/30/2023 by close of business.
Type B
Section Cited
CCR
97465(a)(4)

87465 Incidental Medical and Dental Care

87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in by not completing Medication Administration Record, documenting assistance with self-administered medications for residents, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Facility agreed to provide staff training regarding dispensing medication and documenting assistance with self-administered medications. Proof of correction will be submitted to CCLD by close of business on 6/30/2023.
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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MONUMENT PARK MANOR
FACILITY NUMBER: 331800091
VISIT DATE: 06/23/2023
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Laundry: Laundry area had a washer and dryer.

Centrally Stored Medications: LPA observed a first aid kit with required components. Client medications are secured in a locked kitchen cabinet.

Living/Family room: The family room had a working television. Let-Us-No poster, Long Term Care Ombudsman information, emergency phone numbers, and facility sketch were posted in living room area and entrance hallway.



Yard/Outside Area: A brick wall secured the entire backyard. All outdoor pathways were free of obstructions. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

LPA observed sharps, knives, disinfectants, and cleaning solutions unsecured and accessible to residents in care. Caregiver Gonzales stated assistance with medication was provided to residents for the past three days (6/20-23/2023), but a review of the Medication Administration Record did not document so. Administrator possessed the personnel file cabinet key on their person; therefore, LPA was unable to review personnel records. As a result, LPA issued a total of four (4) deficiencies faulting the facility. An exit interview was conducted, and a copy of this report was reviewed and provided to facility Caregiver Gonzales along with an LIC809-D and Appeals Rights.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
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