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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880633
Report Date: 06/07/2022
Date Signed: 06/07/2022 04:56:54 PM

Document Has Been Signed on 06/07/2022 04:56 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:CALIFORNIA MANOR GUEST HOME #1FACILITY NUMBER:
331880633
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:8536 & 8548 CALIFORNIA AVETELEPHONE:
(786) 219-6008
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 12CENSUS: 10DATE:
06/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:21 PM
MET WITH:Staff- Crease CornistaTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola made an unannounced visit to the facility concerning complaint 18-AS-20220531161914.

The following deficiencies were observed by the staff and LPA:
  • R1 is being served foods that are not in accordance to doctor ordered special diet and food allergies. The facility will receive a type B deficiency for this.


An exit interview was conducted where this report along with 809-D pages were reviewed. Appeal rights were also provided to staff member, Crease Cornista.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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 06/07/2022 04:56 PM - It Cannot Be Edited


Created By: Janira Arreola On 06/07/2022 at 04:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CALIFORNIA MANOR GUEST HOME #1
FACILITY NUMBER: 331880633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2022
Section Cited
CCR
87555(b)(7)

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87555 General Food Service Requirements(b) The following food service requirements shall apply:(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
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Licensee will train staff on R1's special diet and provide R1 with foods that are in accordance to his diet only.
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This regulation was not met evidenced by: R1 being given food that was not inaccordance to doctor ordered diet.
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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 Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


LIC809 (FAS) - (06/04)
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