331881224-12-27-2023-56-AS-RGAR-CYWQ67-20231227105304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881224
Report Date: 12/27/2023
Date Signed: 12/27/2023 10:53:14 AM

Document Has Been Signed on 12/27/2023 10:53 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ARAGON MANOR		FACILITY NUMBER:	331881224
ADMINISTRATOR:	ARAGON, MARIELA		FACILITY TYPE:	740
ADDRESS:	33785 TAMERRON WAY		TELEPHONE:	(951) 245-4244
CITY:	WILDOMAR	STATE: CA	ZIP CODE:	92595
CAPACITY:	4	CENSUS: 3	DATE:	12/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Mariela Aragon- Administrator		TIME COMPLETED:	11:03 AM

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) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Mariela Aragon and was granted entry to the facility. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of four (4) non-ambulatory residents, two (2) residents may be bedridden. The current census is three (3) residents. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to interior and exterior passageways. The inground pool in the backyard is appropriately gated and securely locked. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathrooms to be at 114.2 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident and staff files. Medications are kept inside the kitchen cabinet inaccessible to residents. LPA found that Resident’s R1, R2, and R3 medications were removed from the originally received containers and are being stored in plastic storage containers. The facility will be issued a deficiency for not storing the resident’s medications in the originally received medication containers. Non-perishable and perishable food supply is sufficient for the residents in care. Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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 12/27/2023 10:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ARAGON MANOR	FACILITY NUMBER: 331881224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by interview and observation, the licensee did not comply with the section cited above evidenced by removing medications out of the originally received containers and storing R1, R2, and R3 medications in plastic storage containers which poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 12/28/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87465 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to conduct a medication training with the facility staff and send LPA proof of staff attendance by the POC due date. POC is due by 12/28/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ARAGON MANOR	FACILITY NUMBER: 331881224
	VISIT DATE: 12/27/2023

NARRATIVE

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LPA reviewed three (3) residents files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed five (5) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings.

Based on the observations made during today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D, and LIC811 were discussed and provided to Administrator Mariela Aragon, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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