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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800190
Report Date: 11/05/2024
Date Signed: 11/05/2024 02:06:23 PM

Document Has Been Signed on 11/05/2024 02:06 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:EASTVALE MANOR ASSISTED LIVING LLCFACILITY NUMBER:
331800190
ADMINISTRATOR/
DIRECTOR:
LUMBRIS, CARMELOFACILITY TYPE:
740
ADDRESS:11842 SILVER LOOPTELEPHONE:
(951) 427-1510
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Carmelita Cruz - staffTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analysts (LPA) Mary Rico and Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with staff Carmelita Cruz and was granted entry to the facility. Licensed capacity is (6) current census (3). LPA was accompanied by staff Carmelita Cruz 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 resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, 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. There was a designated office for resident/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. 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 (2) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (2) resident medications, LPA also reviewed (2)staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

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 provided to staff Carmelita Cruz.

Efren MalagonTELEPHONE: (951) 248-0337
Mary RicoTELEPHONE: (951) 248-0293
DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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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