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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426105
Report Date: 08/25/2023
Date Signed: 08/25/2023 11:16:59 AM

Document Has Been Signed on 08/25/2023 11:16 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MEMBERS CLUB WINCHESTERFACILITY NUMBER:
336426105
ADMINISTRATOR:STIEN BAWENGANFACILITY TYPE:
735
ADDRESS:34827 VINEYARD GREEN CT.TELEPHONE:
(951) 926-7920
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 4CENSUS: 0DATE:
08/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Eleonor Sharppe, CaregiverTIME COMPLETED:
11:15 AM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Member's Club Adult Residential Facility unannounced to conduct an Annual Inspection. LPA knocked on the door and was greeted by Caregiver, Eleonor Sharppe, (ES) LPA introduced self and stated purpose of the visit. LPA was granted entry and provided space to work. Administrator was not present, ES contacted Administrator and notified of LPA visit. LPA was accompanied by Eddy Sendow, Caregiver on a walk through of the facility. Staff informed LPA there were no residents present during visit.

The facility is comprised of a two, (2) level residence with four, (4) resident rooms, one (1) staff room, three (3) bathrooms, kitchen, dining area, living room, den, laundry attached garage, and backyard. The facility is vendorized with the Inland Regional Center and designated Level 4I. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating at the capacity approved by Community Care Licensing (CCL). Pathways were observed to be free of obstructions. The facility observed in comfortable temperature. LPA inspected resident bedrooms and found that each room included required furniture such as: mattresses, night stands, adequate storage and sufficient lighting. LPA inspected resident bathrooms; 1 bathroom is for staff. 2 bathrooms are for residents. Bathrooms were observed to clean, appliances functional and contained proper hand hygiene supplies. LPA tested the temperature from the bathroom faucet, which was observed in regulated limits. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Administrator reports disaster drills are conducted on a monthly basis. Last fire/disaster drill documented 8/13/23. Posters such as; the personal rights, letusknow, and disaster plans were posted in a common areas throughout facility. Cleaning supplies, toxins, sharps, and other dangerous items were observed to be kept secure and inaccessible to residents in care. LPA observed designated secure storage spaces for resident/staff files and medications. Medications were secure and inaccessible to residents. Emergency and first aid kits were observed and readily available for residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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 2
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: MEMBERS CLUB WINCHESTER
FACILITY NUMBER: 336426105
VISIT DATE: 08/25/2023
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Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. The facility has a posted food menu; which is published on a weekly basis for breakfast, lunch, dinner and snacks. Facility offers its residents a variety of foods: LPA observed fresh vegetables, fresh fruits, milk and eggs. Dishes, cups, and utensils were observed in proper storage and in adequate amounts. Emergency food and water supply were also observed in the facility's attached
Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members currently employed in the facility have criminal record clearance through the department.
Record Review: LPA reviewed 4 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 1 staff file for First Aid/CPR certification, criminal record clearance, training, and health screenings. Fire extinguisher last inspected June 2023.

Based on observations, interviews and record reviews no deficiencies will be cited per Title 22, California Code of Regulations. An exit interview was conducted. A copy of this report was read/reviewed with Facility Representative; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC809 (FAS) - (06/04)
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