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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880813
Report Date: 11/06/2023
Date Signed: 11/06/2023 02:33:02 PM


Document Has Been Signed on 11/06/2023 02:33 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:NIGHTINGALE CARE OF LOMA LINDA, L.L.CFACILITY NUMBER:
361880813
ADMINISTRATOR:PANGALILA, GEERTRUIDAFACILITY TYPE:
740
ADDRESS:11602 PECANS WAYTELEPHONE:
(562) 256-4642
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 0DATE:
11/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Geertruida Pangalila, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Geertruida Pangalila, Administrator, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) with a current census of (0). LPA observed no residents at the facility during the inspection. The Administrator stated that the facility has not had residents in care since September 8, 2023. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. Outdoor shaded area is sufficient for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. Bathroom showers, faucets, toilets are maintained in operating conditions. The hot water temperature in residents' bathrooms measured 106 degrees F. Resident’s bedrooms have sufficient lighting, furniture, and space for residents. Facility has operating carbon monoxide alarms. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, disaster evacuation plan and emergency telephone numbers.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NIGHTINGALE CARE OF LOMA LINDA, L.L.C
FACILITY NUMBER: 361880813
VISIT DATE: 11/06/2023
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Food Service: The refrigerator and freezer are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas.
Record Review: The facility currently has no staff and no residents in care.

Medical Related Services: LPA observed a locked closet where medications will be centrally stored.

No deficiencies were cited during today’s visit. An exit interview was conducted where this report was discussed and a copy provided to the Administrator at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC809 (FAS) - (06/04)
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