361880646-1-30-2023-56-AS-MMAE-CNKTAC-20230130133319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880646
Report Date: 01/30/2023
Date Signed: 01/30/2023 01:33:26 PM

Document Has Been Signed on 01/30/2023 01:33 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:	WHISPERING WINDS OF APPLE VALLEY ASSISTED LIVING		FACILITY NUMBER:	361880646
ADMINISTRATOR:	MONYA HENRY		FACILITY TYPE:	740
ADDRESS:	11825 APPLE VALLEY ROAD		TELEPHONE:	(760) 961-1212
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92308
CAPACITY:	115	CENSUS: 69	DATE:	01/30/2023
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Executive Director, Monya Henry and Memory Care Director, Jessie Kelly		TIME COMPLETED:	01:36 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	On 1/30/2023 at 9:24 a.m. Licensing Program Analysts (LPAs) Magda Malcore and Rayshaun Nickolas conducted an announced case management visit. The purpose for this visit is in response to the facility's request for an capacity increase and new memory care unit. LPAs Malcore and Nickolas met with Executive Director Monya Henry and Memory Care Director Jessie Kelly who assisted LPAs with facility tour. Per Henry a section of the pre-existing assisted living unit was converted to the memory care unit. A representative from Apple Valley Fire Protection District conducted a fire safety inspection 11/17/2022 and cleared the facility for non-ambulatory and/or bedridden residents located throughout first and second floors with increase capacity of one (1). LPAs observed that the current memory care unit is still under construction. Per Henry construction will be completed on 2/09/2023. LPAs observed no clients residing in the memory care unit during its construction. The memory care unit staff will include two (2) caregivers, one (1) memory care director, and one (1) med technician. The memory care unit is secured. Memory care staff will utilized the unit by using a four (4) digit PIN. Selected memory care staff will be given a key fob which tracks access by name. Per Henry only the memory care staff and all directors will have access to the secured memory care unit. The memory care has a delayed egress that was not activated. However, Henry directed maintenance to activate the delayed egress for LPAs inspection. At 9:37 a.m. LPAs Malcore and Nickolas inspected the memory care unit. The memory care living room area has adequate seating and furniture is in good repair. The kitchenette has new appliances and is in good repair. The kitchenette is connected to dining area. The dining area furniture is in good repair with adequate seating for 20 people. LPAs observed three (3) pull cords in the dining area.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

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

FACILITY NAME: WHISPERING WINDS OF APPLE VALLEY ASSISTED LIVING	FACILITY NUMBER: 361880646
	VISIT DATE: 01/30/2023

NARRATIVE

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LPAs inspected eight (8) private rooms and five (5) shared rooms. LPAs observed that all rooms had new mattresses and pull cords however, rooms did not have much furniture do to being under current construction. All bathrooms had handrails and pull cords. LPAs observed that the model unit had required bedding and furniture such as new mattress/linen, sufficient storage space, chairs and lighting. Model unit bathroom had towels, grab rails near the toilet and in the shower. LPAs also observed that the water temperture in the bathroom was 109 degrees fahrenheit. LPAs ended tour in the sun room which had adequate seating and furniture was in good repair. The sun room french doors has access to an enclosed courtyard.

No deficiencies we cited during this visit. An exit interview was conducted where this report was discussed and provided to Henry.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC809 (FAS) - (06/04)

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