361880856-5-5-2023-56-AS-VCHN-CRJPTY-20230505113642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880856
Report Date: 05/05/2023
Date Signed: 05/05/2023 11:37:01 AM

Document Has Been Signed on 05/05/2023 11:37 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:	BRIDGE WATER MANOR		FACILITY NUMBER:	361880856
ADMINISTRATOR:	HANNER, CYNTHIA		FACILITY TYPE:	735
ADDRESS:	12750 BRIDGE WATER DRIVE		TELEPHONE:	(909) 463-0321
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91739
CAPACITY: 4		CENSUS: 4	DATE:	05/05/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Cynthia Hanner- Administrator		TIME COMPLETED:	11:50 AM

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) Victoria Chitgian arrived unannounced to the facility for a required annual inspection. Facility is an Adult Residential Facility licensed for four (4) ambulatory clients. LPA met with Administrator Cynthia Hanner. At the time of the visit, one client was present at the facility. LPA toured the facility inside and outside. Outdoor and indoor passageways were kept free of obstruction. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. LPA toured the kitchen. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review and included nutritious options. LPA toured the client bedrooms. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 4/10/2023. Cleaning supplies were stored under the sink and laundry areas. Centrally stored medications were kept in a safe and locked cabinet. LPA toured the client bathrooms. LPA measured the hot water temperature in the bathrooms and kitchen. The hot water temperature in the client bathroom measured 106 degrees Fahrenheit. The outside of the facility had a shaded area with a table and chairs. The facility does has a pool that is fenced and inaccessible to clients. LPA observed several cans of paint and primer, in the backyard. LPA advised the Administrator that hazardous substances need to be inaccessible to clients. Administrator proceeded to lock the paint in a storage shed. Technical Violation issued. LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. Administrator file contained required files and records. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. Two client files lacked the required “No objection to placement”. Administrator will follow up with the Consumer Service Coordinator(CSC) during the next scheduled visit. Technical Assistance issued.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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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Document Has Been Signed on 05/05/2023 11:37 AM - It Cannot Be Edited

Created By: Victoria Chitgian On 05/05/2023 at 11:13 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BRIDGE WATER MANOR	FACILITY NUMBER: 361880856
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80072(e)

(e)The information specified … including the visiting policy as stated in the admissions agreement shall be prominently posted in areas accessible to clients and their visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above as the facility Visitation Policy is not prominently posted in a common area, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Administrator will create and post a Visitation policy in a common area and submit proof to Licensing Program Analyst by POC date above.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Efren Malagon

LICENSING EVALUATOR NAME:

Victoria Chitgian

LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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: BRIDGE WATER MANOR	FACILITY NUMBER: 361880856
	VISIT DATE: 05/05/2023

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LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. Licensee has secured each consumer’s personal property and cash resources. Required Visitation Policy posting was not visible in a common area. Deficiency was issued. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care.
One(1) deficiency was issued during this visit. One technical violation, and one technical assistance. An exit interview was conducted where this report, LIC 809, LIC 809-D, LIC 9102, and appeal rights was discussed and provided to the Administrator, at the end of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

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