361880646-4-6-2023-56-AS-RNIS-CQMSXX-20230406141641

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880646
Report Date: 04/06/2023
Date Signed: 04/06/2023 02:16:48 PM

Document Has Been Signed on 04/06/2023 02:16 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, 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:	04/06/2023
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	01:57 PM
MET WITH:	Monya Henry, Executive Director		TIME COMPLETED:	02:22 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 04/06/2023 at 1:57p.m., Licensing Program Analyst, (LPA) Rayshaun Nickolas conducted an announced visit to this facility to inspect the new Memory Care Unit which has been added to the facility. On 3/16/23 Apple Valley Fire Department issued an approved Fire Inspection report which includes the Memory Care Unit for a capacity of 18 beds. The fire inspection and fire clearance for the memory care unit includes delayed egress, secured perimeter. This facility entire facility is cleared for capacity of 116 non-ambulatory residents none of whom may be bedridden. Fire clearance was granted for the newly constructed Memory Care Unit. LPA Nickolas toured the new Memory Care Unit with Executive Director Monya Henry, to ensure compliance with Title 22 Regulations. Prior to today’s visit Community Care Licensing Division (CCLD) received the following documents to process the new Memory Care Unit: an addendum to the plan of operation related to care of persons with dementia, an application (LIC 200), the facility sketch floor plan, and the approved Fire safety inspection. The Memory Care Unit is secured and has delayed egress with door alarms and other monitoring / alert systems. Medication room: The memory Care unit has a medication room located inside the unit. A keypad secures the medication room. To gain access to the medication room, facility staff must utilize their four (4) digit code. Living room: The living room has four (4) recliners, four oversized stationary chairs, and a love seat that seats two (2). All the living room furniture is in good repair. The living room also has a television. Dining Area: The dining area has five tables and four chairs at each table. All dining furniture is in good repair. The dining area also has three pull cords.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: WHISPERING WINDS OF APPLE VALLEY ASSISTED LIVING	FACILITY NUMBER: 361880646
	VISIT DATE: 04/06/2023

NARRATIVE

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Kitchenette: The kitchenette has an open-concept design that opens to the dining area. The kitchenette appliances are in good repair. During a previous visit to the facility on January 30, 2023, Henry advised LPA Nickolas and Malcore that food would only be prepared in the facility's kitchen.

Bedrooms: The memory care unit has 18 bedrooms, each with a pull cord.

Bathrooms: The memory care unit has 18 bathrooms. Each bathroom has pullcords, grab bars in the shower, and grab bars near the toilet.

Sunroom: The sunroom has two (2) oversized stationary chairs and one (1) pull cord. The sunroom provides clients access to the secured courtyard. The sunroom's French doors are secured. Facility staff must enter their four (4) digit code on the keypad to grant clients access to the courtyard.

Courtyard: The courtyard is secured by perimeter fencing. The courtyard provides clients with plenty of shaded seating. The courtyard furniture is in good repair.

Activities: The facility’s activities are posted on a television in the hall near the living room.

An exit interview was conducted. LPA notified Henry the approval is pending management review.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC809 (FAS) - (06/04)

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