331881230-12-4-2024-18-AS-SMAZ-DBMRYD-20241204122610

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881230
Report Date: 12/04/2024
Date Signed: 12/04/2024 12:26:14 PM

Document Has Been Signed on 12/04/2024 12:26 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	JNJ MAPLE RESIDENTIAL CARE		FACILITY NUMBER:	331881230
ADMINISTRATOR/ DIRECTOR:	NEIL JABONERO		FACILITY TYPE:	735
ADDRESS:	26480 MAPLERIDGE WAY		TELEPHONE:	(951) 992-1166
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY: 4		CENSUS: 4	DATE:	12/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:28 AM
MET WITH:	Niel Jabonero, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:30 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), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. On today’s visit the LPA met with Administrator, Neil Jabonero; he was notified of the purpose for the visit. INFECTION CONTROL: The facility has an infection control plan in place that is being reviewed regularly for any needed updates and/or changes. The Administrator reported the plan is being followed by staff whenever there are any clients in care who present with infections. PHYSICAL PLANT AND ENVIRONMENTAL SAFETY: The Licensee appears to be operating the facility within the conditions and limitations specified on the license. Clients appear to be protected against immediate hazards. Outdoor and indoor passageways are kept free of obstruction. No pool or other body of water was observed on the property. The Administrator reported there are no weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to clients in care. A comfortable temperature was being maintained in the home. There was sufficient lighting in all rooms to ensure the comfort and safety of clients. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. The smoke and carbon monoxide alarms were tested and found to be operable. The interior and exterior areas of the home were observed to be very clean and safe. Operational Requirements: The Licensee has secured and appears to be maintaining the approved fire clearance. Proof of training in reporting requirements was observed on file. The licensee appears to be providing for all client's activities of daily living needs, including supervision. A plan for providing clients with activities is being followed. STAFFING: Facility personnel appear to be competent to provide the necessary services to meet individual client needs. Review of the facility's staff schedule revealed two staff members are scheduled per shift. Per Administrator, two to three staff are scheduled at a time. He reported there is currently sufficient staffing available to meet client needs. Administrator reported night staff are available to provide clients with care and supervision. He reported night staff are on call and on the premises, as required. Staff are trained in emergency procedures. PERSONNEL RECORDS - TRAINING: The Administrator appears to be on the premesis sufficient number of hours to

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

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

FACILITY NAME: JNJ MAPLE RESIDENTIAL CARE	FACILITY NUMBER: 331881230
	VISIT DATE: 12/04/2024

NARRATIVE

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manage and administer the facility. Administrator has an active Administrator's Certificate and proof of HIV and TB training is on file. All staff members have had health screenings completed with TB test results listed. Staff present had the required criminal record clearances. Documentation of criminal record clearances were observed on file. Staff files had required training; including, but not limited to, medication training and First Aid/CPR training. CLIENTS RIGHTS - INFORMATION: An internet accessible device is available for clients use. Food Service: The LPA inspected the facility's kitchen areas and food supply. Administrator reported three meals per day are provided. The LPA observed all food to be of good quality. All readily perishable foods and beverages were stored in covered containers at appropriate temperatures. Soaps, detergents, cleaning compounds and similar substances were stored in areas separate from food supplies. All kitchen areas were kept clean and free of litter, rodents, vermin, and insects. According to Administrator, there are no clients in care who require a modified diet. He reported staff members who engage in food preparation and services follow personal hygiene and food services sanitation practices. Kitchen ware was observed to be in good condition and sufficient for each clients in care. Kitchen equipment and appliances were observed to be in working order. CLIENT RECORDS - INCIDENT REPORTS: All clients had individual written admission agreements on file. Written certification regarding no objections to the placement of the clients by the Inland Regional Center (IRC) was observed on file. Additional required records were observed to be on file and complete, including, but not limited to, medical assessments (including TB test results), needs and service plans, and centrally stored medication and destruction records. Health Related Services: The licensee is ensuring client's first aid and other needed medical or dental needs are being met for each client in care. Clients are being assisted with administration of prescribed medications. According to Administrator, all clients are able to communicate their symptoms clearly, if they are prescribed PRN medications. Client medications were observed to be appropriately labeled. Medications were observed to be centrally stored in a safe and locked area. Staff are assisting clients who require assistance with bowel and/or bladder incontinence. INCIDENTAL MEDICAL SERVICES: According to Administrator, there are no clients in care who have a Restricted or Prohibited Health Condition. DISASTER PREPAREDNESS: The facility has an emergency plan on file and proof of emergency drills was observed to be completed. EMERGENCY INTERVENTION: According to Administrator, manual restraint and/or seclusion procedures are not being practiced at the facility. EXIT: The home appears to be operating well within regulatory requirements. This report was reviewed with Administrator Jabonero and a copy was provided. No deficiencies were cited at time of inspection.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

LIC809 (FAS) - (06/04)

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