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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336407346
Report Date: 12/11/2023
Date Signed: 12/11/2023 12:00:04 PM


Document Has Been Signed on 12/11/2023 12:00 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:WILDOMAR SENIOR ASSISTED LIVINGFACILITY NUMBER:
336407346
ADMINISTRATOR:CRISTINA MILLERFACILITY TYPE:
740
ADDRESS:32365 SOUTH PASADENA ST.TELEPHONE:
(951) 678-1555
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY:152CENSUS: 88DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Cristina Miller- AdministratorTIME COMPLETED:
12:10 PM
NARRATIVE
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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 Cristina Miller and was granted entry to the facility.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of one-hundred-fifty-two (152) residents, thirty (30) residents may be non-ambulatory, and fifty (50) residents may be bedridden. The current census is eighty-eight (88) residents. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to interior and exterior passageways. 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 119.6 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 medication room inaccessible to residents. Overall, the facility is clean and in good repair.



Food Service: Non-perishable and perishable food supply is sufficient for the residents in care. During kitchen/refrigerator tour, LPA found moldy cheese and moldy apples, expired yogurt, expired buttermilk, and expired milk. The facility will be issued a deficiency for not covering the food correctly allowing mold to grow and for having expired food.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
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 3


Document Has Been Signed on 12/11/2023 12:00 PM - 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: WILDOMAR SENIOR ASSISTED LIVING
FACILITY NUMBER: 336407346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced based on interview and observation, the licensee did not comply with the section cited above evidenced by not have having cheese and apples properly covered in the refrigerator which caused mold to grow on the food which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 12/18/2023
Plan of Correction
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The licensee has agreed to read regulation 87555 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to conduct a food training with the facility staff and send LPA proof of staff attendance by the POC due date. POC is due by 12/18/2023.
Type B
Section Cited
CCR
87555(b)(9)
87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced based on interview and observation, the licensee did not comply with the section cited above evidenced by having expired yogurt, expired milk, and expired buttermilk in the refrigerator which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 12/18/2023
Plan of Correction
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The licensee has agreed to read regulation 87555 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to conduct a food training with the facility staff and send LPA proof of staff attendance by the POC due date. POC is due by 12/18/2023.
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: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: WILDOMAR SENIOR ASSISTED LIVING
FACILITY NUMBER: 336407346
VISIT DATE: 12/11/2023
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 Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed eight (8) residents files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed eight (8) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were audited and appeared to be dispensed appropriately.

Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

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

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC809 (FAS) - (06/04)
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