<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881001
Report Date: 10/06/2020
Date Signed: 10/21/2020 10:12:22 AM

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:BARDWELLS PINES MANOR LLCFACILITY NUMBER:
331881001
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:5336 BARDWELLS AVETELEPHONE:
(786) 219-6008
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY:6CENSUS: 4DATE:
10/06/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Najeh "Nick" HamedTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kathleen Wiggins conducted an announced pre-licensing video conference inspection to the facility due to COVID-19. LPA met with Najeh "Nick" Hamed. Currently there are four (4) residents in care. The facility is currently licensed and is under a change in ownership. The application is for a six (6) bed, Residential Care Facility for the Elderly for six (6) non-ambulatory and a hospice waiver for two (2).

All bedrooms are furnished with bed, nightstand, dresser and chair. Bedrooms have adequate lighting for residents’ use. The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The water temperature was tested and measured at 108.7 degrees Fahrenheit. The smoke and carbon monoxide alarms were tested and are in operating order. LPA observed fire doors to be properly functioning. Fire extinguishers are present in the facility and fully charged. The kitchen was observed to have dishes, silverware, pots, and pans. Knives are locked in kitchen drawer. Staff and resident files will be locked in a file cabinet in the cabinet. The medications will be locked in medicine cabinet located in the cabinet. A complete first aid kit was observed and to be complete. The chemicals will be locked and kept in the laundry area and under the kitchen sink. The backyard was observed to be fully fenced with an unlocked gate and had covered patio, table and chairs for client’s comfort while sitting outside. The phone number designated for the facility is (951) 684-0400. There is an emergency exit, free of obstruction. The fire inspection was conducted and approved.

The facility was evaluated in accordance with the CCR, Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of clients in care. Facility appears to be ready for licensure.

An exit interview was conducted, and a copy of this report was reviewed and provided to Mr. Hamed via email to obtain signature.

Receipt of report was confirmed.
SUPERVISOR'S NAME: Leslie MendivelesTELEPHONE: (951) 248-2222
LICENSING EVALUATOR NAME: Kathleen WigginsTELEPHONE: (951) 205-7142
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020
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 1