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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425056
Report Date: 07/24/2024
Date Signed: 07/24/2024 11:59:02 AM

Document Has Been Signed on 07/24/2024 11:59 AM - 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:MANITOBA RESIDENTIAL CAREFACILITY NUMBER:
336425056
ADMINISTRATOR/
DIRECTOR:		CHARISSE MCCOYFACILITY TYPE:
735
ADDRESS:1703 MANITOBA CIRCLETELEPHONE:
(951) 531-8952
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 5CENSUS: 4DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator Charisse Mccoy TIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Sarina Ramirez and Mary Rico conducted an unannounced required annual inspection to the facility. LPAs met with Administrator Charisse Mccoy and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), level 4i. The facility is an Inland Regional Center (IRC) certified vendor with a license capacity of (6) and a current census of (4). LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant & Operation: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Facility's backyard is enclosed and gated. Indoor and outdoor activity areas are sufficient for clients in care. Client activities include community outings and day program participation. The facility has sufficient lighting and is maintained at a comfortable temperature. Client bathrooms were operating in sanitary conditions. The hot water temperature measured at 109 and 108 degrees F. Client bedrooms have sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms, laundry equipment and telephone service. The facility has sufficient linen and personal hygiene items for clients in care. The facility has posted in a common area disaster evacuation plan, emergency telephone numbers, facility license, house rules, personal rights poster, and food menu.


Food Service: The facility has sufficient non-perishable and perishable food supply for clients in care. Sharps were kept locked, no chemicals stored in kitchen area. The facility's refrigerator temperature measured at 37 degrees F and the freezers’ temperature measured at -7 degrees F.
**** Continuation on LIC 809 – C****
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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: MANITOBA RESIDENTIAL CARE
FACILITY NUMBER: 336425056
VISIT DATE: 07/24/2024
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Care & Supervision: Facility has 24 hour care staff. Staff working have criminal record clearances.

Record Review: Review of (2) Client files were observed, Client 1 (C1) had an incomplete P&I. During record review LPAs Ramirez and Rico discovered that the LIC405 was not updated for July. The documentation last updated was on 6/23/2024 with the balance of $158.71. The current balance that was provided is $ 81.25, a Deficiency will be issued. Review of (2) staff files were observed to be complete.

Medical Related Services: All client medication is centrally stored and kept in a locked cabinet.

Based on observations and record review, one (1) Type B deficiency will cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where the Licensing reports were discussed and copies of the reports with Appeal Rights was provided to Administrator Charisse Mccoy.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2024 11:59 AM - It Cannot Be Edited


Created By: Sarina Ramirez On 07/24/2024 at 11:43 AM
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: MANITOBA RESIDENTIAL CARE
FACILITY NUMBER: 336425056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 4 clients had an incomplete P&I which poses a potential health, safety or personal rights risk to persons in care
POC Due Date: 07/31/2024
Plan of Correction
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Licensee has agreed to send LPA Ramirez proof of C1 updated LIC405.
Section Cited
Deficient Practice Statement
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3
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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:Karen Clemons
LICENSING EVALUATOR NAME:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
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