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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880633
Report Date: 03/23/2022
Date Signed: 03/24/2022 11:05:19 AM

Document Has Been Signed on 03/24/2022 11:05 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
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: 11DATE:
03/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ahmad Abdallatef, House ManagerTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Stephanie Torres and Chinwe Nwogene, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPAs met with House Manager, Ahmad Abdallatef, and informed him of the purpose of the visit. There are currently no cases of COVID-19 within the facility.

During today's visit, the LPAs toured the facility and made observations pertaining to the facility's infection control measures. The LPAs observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring cleaning and disinfection provisions are in adequate quantities, and overall infection control. The facility has a Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report and is pending review.

During this visit the LPAs observed various medications stored in the bedroom of Resident One (R1). The medical assessment for R1 was reviewed and it was observed the resident is unable to manage their own medications. A citation will be issued.

An exit interview was conducted with Abdallatef, this report was reviewed and a copy was provided, along with Appeal Rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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 2
Document Has Been Signed on 03/24/2022 11:05 AM - It Cannot Be Edited


Created By: Stephanie Torres On 03/23/2022 at 01:10 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: 03/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(1)(B)


Incidental Medical and Dental Care: The following requirements shall apply to medications which are centrally stored:
Medications shall be centrally stored under the following circumstances: Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, the Licensee did not ensure medications were centrally stored for R1. The LPAs observed medications in the bedroom of R1. R1's medical assessment revealed they are not able to administer their own medications.
POC Due Date: 03/23/2022
Plan of Correction
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Staff removed all medications from R1's bedroom and stored it inaccessible to all unauthorized individuals.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Stephanie Torres
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022


LIC809 (FAS) - (06/04)
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