<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408482
Report Date: 11/25/2024
Date Signed: 11/25/2024 12:22:31 PM

Document Has Been Signed on 11/25/2024 12:22 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:CUNNINGHAM RES. CARE HOME IIIFACILITY NUMBER:
336408482
ADMINISTRATOR/
DIRECTOR:		ALICIA CUNNINGHAMFACILITY TYPE:
740
ADDRESS:24702 ORMISTADRIVETELEPHONE:
(951) 485-4697
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:Licensee and Administrator, Alicia CunninghamTIME 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) Janira Arreola conducted a required annual visit. LPA met with Licensee and Administrator, Alicia Cunningham, who was informed of the purpose of the visit. At time of visit there was (1) resident and (3) staff present.

The facility is a one story home with (5) bedrooms and (2) bathrooms with attached garage. The facility does not have a pool or fire arms. The facility is designated as a residential care facility for the elderly. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Infection Control: LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has an infection control plan and documented training for staff on infection control.

Physical Plant: Physical plant, floors, windows, and doors were observed, along with fixtures and furniture. The facility's outdoor area was observed to be free of hazards and contained outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 118.5F.

Based on LPA observations of posted facility sketch work permits and observation of the facility restrooms have been renovated. The restrooms are functioning and completed during today's visit. Remodeling was initiated on 11/6/2024 per the signed work permits. Based on Licensee and staff interviews the renovations were conducted (1) restroom at a time. Technical note was documented as the licensee stated they were not aware of the need to inform Licensing of the renovations. Licensee stated they would inform licensing of any future renovations, relocations or related incidents occurring at the facility. The licensee agreed to send the LPA a written notification pending the city walk through and approval of the work conducted.

Food Service: LPA observed facility kitchen possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
Tricia DanielsonTELEPHONE: (951) 202-5067
Janira ArreolaTELEPHONE: 951-233-6759
DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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
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: CUNNINGHAM RES. CARE HOME III
FACILITY NUMBER: 336408482
VISIT DATE: 11/25/2024
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
26
27
28
29
30
31
32
 Record Review and Resident/Staff Files: LPA reviewed staff files and training which met the department requirements along with criminal clearance. The staff schedule show adequate staff coverage. Resident files were reviewed and possessed all required paperwork. The facility does not currently provide cash handling to residents in care.

Based on LPA file review, Licensee was informed the current copy of the lease agreement for the home is needed to update the facility file, as well as any dementia care plan. Licensee agreed to send this to LPA by 12/6/2024.

LPA reviewed the licensee's file and found all required personnel paperwork. The administrator certificate posted expired 7/24/2022. The licensee stated they had renewed their certificate but had not received it in the last (2) years. Technical note was documented for the licensee to send proof of check and certified mail package sent to renew their certificate. The licensee agreed to send this to the LPA to inquire on the administrator's status as the Department website and public line does not have a current status for the renewal by 12/6/2024. The Department is currently behind on renewals and a deficiency will not be cited at this time.

Health Related Services/ Incidental Medical Services: All resident medication was locked in a kitchen cabinet. LPA reviewed resident medications for (2) residents. LPA found all medication accounted for on the Medication Administration Record (MAR).

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted 9/21/2024. LPA observed all facility exits were clear from obstructions. The facility posses a complete first aide kit and emergency supplies.

An exit interview was conducted where a copy of this report was reviewed and provided.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4