<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880818
Report Date: 11/22/2024
Date Signed: 11/22/2024 04:31:04 PM

Document Has Been Signed on 11/22/2024 04:31 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DIVINE MANOR CARE INCFACILITY NUMBER:
361880818
ADMINISTRATOR/
DIRECTOR:		YADAV, SHREETAFACILITY TYPE:
740
ADDRESS:6367 MARBLE AVETELEPHONE:
(347) 449-2449
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:52 PM
MET WITH:Shreeta Yadav, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:40 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
Licensing Program Analyst (LPA) LaVette Farlow arrived unannounced to conduct the required annual visit to the facility. LPA met with Caregiver, Roldan Kiseo, and introduced self and stated purpose of the visit. Caregiver Roldan notified Administrator of my arrival and state the house manager will be arriving to the facility. LPA met with Carmen Holden and explain the purpose of the visit and a tour was conducted. LPA was informed that there are currently 5 residents in care and (1) resident in the hospital.

The facility has 5 resident bedrooms, 3 bathrooms, kitchen, dining area, living room, attached garage, and backyard. LPA completed a walk through of facility, review of records and medication audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 107.2, 105.2, 109.1 and 107.7 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, 3 fire extinguishers and emergency kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. LPA observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed in a secured filing cabinet and inaccessible to residents. LPA observed two (2) out of two (2) residents MARS were not properly initialed. Technical violation issued. There are no firearms, ammunition, swimming pool or bodies of water. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: LPA observes that the facility did not maintain a sufficient amount of non-perishable and perishable food supply for 7 days for number of residents in care. Technical violation issued. Dishes, cups, and utensils were also stored properly.
Nedra BrownTELEPHONE: (951) 202-5776
Lavette FarlowTELEPHONE: 951-248-0304
DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIVINE MANOR CARE INC
FACILITY NUMBER: 361880818
VISIT DATE: 11/22/2024
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
26
27
28
29
30
31
32
Yards/Outside: Two shaded patio, a side gate with self-latching handle on the right and left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings. LPA observed the Emergency Disaster Plan not signed and dated. Technical violation issued. LPA observed emergency drills not conducted on each shift. Technical violation issued.

Three technical violations were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, and LIC9102TV were discussed and copies were provided to Administrator Shreeta Yadav.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Lavette FarlowTELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2