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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880691
Report Date: 08/28/2024
Date Signed: 08/28/2024 03:22:42 PM


Document Has Been Signed on 08/28/2024 03:22 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:MDPR & ASSOCIATES- MOUNTAIN SENIOR CARE HOMEFACILITY NUMBER:
331880691
ADMINISTRATOR:DIAZ, MARLENFACILITY TYPE:
740
ADDRESS:2005 MOUNTAIN AVETELEPHONE:
(951) 737-8027
CITY:NORCOSTATE: CAZIP CODE:
92860
CAPACITY:6CENSUS: 4DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Administrator Marlen DiazTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Marlen Diaz, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (4). LPA Ramirez conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility does not have a swimming pool or similar bodies of water. Outdoor shaded area is sufficient for resident activities and is enclosed with self-latching gates. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility is equipped with operating smoke detectors/carbon monoxide alarms, laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating in a safe and sanitary conditions. The hot water temperature in residents bathroom measured at 106 degrees F. Three (3) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, complaint poster, Ombudsman poster, facility license, disaster facility sketch, food menu, and activities.

Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps were kept locked and inaccessible to residents in care.

Continuation on LIC – 809C:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina RamirezTELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MDPR & ASSOCIATES- MOUNTAIN SENIOR CARE HOME
FACILITY NUMBER: 331880691
VISIT DATE: 08/28/2024
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Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff have current CPR/first aid training.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet.

Record Review: Four (4) Staff files reviewed were observed to be complete. Four (4) Resident files reviewed were observed to be complete.

Based on observations and record review no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.


An exit interview was conducted where the Licensing reports were discussed and a copy was provided to Administrator Marlen Diaz .
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina RamirezTELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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