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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881291
Report Date: 05/03/2023
Date Signed: 05/03/2023 02:40:31 PM

Document Has Been Signed on 05/03/2023 02:40 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MONUMENT PARK HOME, INCFACILITY NUMBER:
331881291
ADMINISTRATOR:NAVARRO, NELLYFACILITY TYPE:
735
ADDRESS:3365 SEQUOIA CTTELEPHONE:
(951) 347-2401
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 5CENSUS: 0DATE:
05/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Johnpaul NavarroTIME COMPLETED:
02:50 PM
NARRATIVE
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On 05/03/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene met with Licensee’s son, Johnpaul Navarro who was informed the purpose of the visit. At the time of visit there was 0 staff and 0 residents present. LPA spoke to Licensee, Xavier Navarro via telephone call, Xavier stated facility has not had any client since license was obtained. LPA toured the facility inside and out with Johnpaul Navarro.

Tour included:

Kitchen; LPA toured the kitchen and observed kitchen to be clean. Utensils and dishware are sufficient for the approved capacity. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen cabinet under the sink, available only to authorized individuals. Trash cans has tight-fitting lids. Dishwasher is to be used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 40 degrees Fahrenheit and Freezer was measures at 0 degrees Fahrenheit.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 66 degrees Fahrenheit which is below regulatory requirement. Citation will be issued.

Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medication; LPA observed a locked medication cabinet located in the Nook. The first aid kit was complete.

Continue on LIC809-C

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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 4
Document Has Been Signed on 05/03/2023 02:40 PM - It Cannot Be Edited


Created By: Chinwe Nwogene On 05/03/2023 at 02:10 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: MONUMENT PARK HOME, INC
FACILITY NUMBER: 331881291

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having an infection control plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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The Licensee stated the Infection Control Plan will be completed and submitted to LPA by the POC due date 5/12/2023.
Type B
Section Cited
CCR
80088(a)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by having the room temperature at 66 degrees fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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The Licensee stated the room temperature will be adjusted and a proof will be provided to LPA by the POC due date 5/12/2023.
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:Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/03/2023 02:40 PM - It Cannot Be Edited


Created By: Chinwe Nwogene On 05/03/2023 at 02:10 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: MONUMENT PARK HOME, INC
FACILITY NUMBER: 331881291

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by having the hot water temperature at 70 degrees fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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The Licensee stated the hot water temperature will be adjusted and a proof will be provided to LPA by the POC due date 5/12/2023.
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:Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MONUMENT PARK HOME, INC
FACILITY NUMBER: 331881291
VISIT DATE: 05/03/2023
NARRATIVE
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Continued from LIC809.

Bathroom; LPA toured two hallway bathrooms and observed bathrooms to be clean and equipped with grab bar. There is also a good number of personal toiletries available for the residents. The hot water measured at 70 degrees Fahrenheit which i below the regulatory requirement. A citation will be issued.

Bedroom; LPA toured four #4 out of #4 residents bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility. Resident bedroom #2 has a private bathroom. LPA observed bathroom to be clean and hot water was measured at 70 degrees Fahrenheit.

Garage; LPA tour the garage and observed garage to be clean and not cluttered. Cleaning supplies are stored away in the garage, inaccessible to clients.

Laundry; LPA toured the laundry room and observed laundry room to be clean. Washing machine and dryer are all in good repair and sufficient for the approved census.

Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gates remain unlocked. No bodies of water were observed.

Food Services: LPA observed seven days non-perishable and all food was properly stored. Due to facility has no client in care, LPA did not observe any perishable food supply.

Records: All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expires on 04/19/2024. LPA inquired about facility infection control plan. Xavier stated facility current has no infection control plan. A citation will be issued.

Interview; Facility currently has no staff and clients.

Therefore, based on the observations made during today’s visit, three #3 citations will be issued per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted, and this reported was reviewed with Licensee, Xavier Navarro via telephone call and a copy provided along with appeal rights to Johnpaul Navarro.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC809 (FAS) - (06/04)
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