336408394-11-7-2024-56-AS-BSIH-DASSHU-20241107125408

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336408394
Report Date: 11/07/2024
Date Signed: 11/07/2024 12:54:16 PM

Document Has Been Signed on 11/07/2024 12:54 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CUNNINGHAM RESIDENTIAL CARE HOME II		FACILITY NUMBER:	336408394
ADMINISTRATOR/ DIRECTOR:	ALICIA CUNINGHAM		FACILITY TYPE:	740
ADDRESS:	4972 SIERRA VISTA		TELEPHONE:	(951) 324-1179
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92505
CAPACITY: 12	TOTAL ENROLLED CHILDREN: 0	CENSUS: 10	DATE:	11/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Facility-Administrator Alicia Cunningham		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Beena Singh met with Staff and was granted entry to the facility. At the time of the visit there were three (3) staff present, and six (6) residents present. Administrator Alicia Cunningham was contacted and arrived during the visit.

The facility is a seven (7) bedroom, three (3) bathroom home with a kitchen/dining area, living room and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of twelve (12) residents of which (6) can be non-ambulatory residents and six (6) ambulatory residents. The facility has two (2) Hospice Waiver and side chain links may be locked in evenings. The current census is ten (10) residents. LPA Beena Singh was accompanied by Staff #2 (S2) 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). LPA Beena Singh observed no obstructions to outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night-stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed non-skid mat or strips in the resident bathrooms.

LPA Beena Singh observed sufficient furniture and lighting throughout the facility. LPA Beena Singh measured and observed the water temperatures in the bathroom to be at 115 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Personal rights and the Ombudsman poster, CCL complaint poster disaster plan were posted in a common area.

Moreover, during the tour of the facility, LPA observed that there was a designated storage space for resident/staff files and a cabinet with the resident’s medications locked.

Efren Malagon	TELEPHONE: (951) 202-6356
Beena Singh	TELEPHONE: (951) 248-2222
	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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

FACILITY NAME: CUNNINGHAM RESIDENTIAL CARE HOME II	FACILITY NUMBER: 336408394
	VISIT DATE: 11/07/2024

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Food Service: Seven (7) days non-perishable food and three (3) days perishable food supply were observed at the facility.

Care & Supervision: The facility has an administrator present in the facility. LPA Beena Singh observed enough staff to provide care and supervision to the residents in care.

Record Review: LPA reviewed ten (10) resident files for admission agreements, updated physician reports, and needs and services plans. The files were complete with updated physician’s reports, admissions agreements, and Pre-placement appraisals and Appraisal/Needs and Services Plan. LPA reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA found that all staffs have CPR training, staff are properly trained in medication, dementia care, and basic training required for an RCFE.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report were discussed and provided to Administrator Alicia Cunningham.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Beena Singh	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

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