361880887-4-22-2024-56-AS-MMAE-D4KQV6-20240422122951

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880887
Report Date: 04/22/2024
Date Signed: 04/22/2024 12:33:07 PM

Document Has Been Signed on 04/22/2024 12:33 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:	ANCHETA'S PLACE		FACILITY NUMBER:	361880887
ADMINISTRATOR:	ANCHETA, EDNA A		FACILITY TYPE:	740
ADDRESS:	1350 OPAL AVENUE		TELEPHONE:	(909) 810-1044
CITY:	MENTONE	STATE: CA	ZIP CODE:	92359
CAPACITY:	2	CENSUS: 2	DATE:	04/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:38 AM
MET WITH:	Edna Ancheta - Administrator		TIME COMPLETED:	12:35 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) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Edna Ancheta, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (2) non-ambulatory residents and a current census of (2) residents in care. The facility has a Hospice waiver for (2). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor shaded area is sufficient for resident activities and is enclosed with a self-latching gate.The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s shower, toilet, and hand washing area was operating in a safe and sanitary condition. The hot water temperature in resident's bathroom measured 110 degrees F. Resident’s bedroom had sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms, signal system and telephone service. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted facility license, Community Care Licensing complaint poster, Ombudsman poster, Personal Rights, disaster evacuation plan and emergency telephone numbers. Sharps, disinfectants, and cleaning solutions were kept locked and inaccessible to residents in care. Care & Supervision: Facility has 24-hour, 7 days a week care staff. Facility staff has CPR/first aid training.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

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: ANCHETA'S PLACE	FACILITY NUMBER: 361880887
	VISIT DATE: 04/22/2024

NARRATIVE

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Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. The facility's two (2) refrigerators and three (3) freezers were operating in a healthful manner.

Record Review: Two (2) staff files reviewed were observed to be complete. Two (2) resident files reviewed were observed to be complete. The facility Administrator’s certification is current. The facility’s last emergency drill was conducted on 1/15/2024.

Medical Related Services: Resident’s medications were labeled and centrally stored in a locked cabinet. The facility has a complete first aid kit.

Based on LPA observations and record review, 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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

LIC809 (FAS) - (06/04)

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