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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880961
Report Date: 10/10/2024
Date Signed: 10/10/2024 06:10:46 PM

Document Has Been Signed on 10/10/2024 06:10 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:MISSION AT RAMONAFACILITY NUMBER:
361880961
ADMINISTRATOR/
DIRECTOR:		ANDREW GONZALEZFACILITY TYPE:
735
ADDRESS:7179 RAMONA AVETELEPHONE:
(909) 328-9790
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 4CENSUS: 4DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:37 PM
MET WITH:Andrew Gonzales, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:19 PM
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Licensing Program Analysts (LPAs) La Vette Farlow and Magda Malcore arrived to conduct the required annual visit to the facility. LPAs met with Administrator Andrew Gonzalez, and introduced themselves and stated purpose of the visit. LPAs were informed that 3 clients are currently in the home and 1 client is currently in a college program.
The facility has 4 resident bedrooms, 2 bathrooms, extra bedroom for staff and one storage room with a bed, office area, kitchen, dining area, family room, living room, laundry area, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPAs completed a walk through of facility, review of records, medication and P&I 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 76 degrees fahrenheit. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPAs inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 127.6 and 121.9 degrees fahrenheit. The staff adjusted the water temperature and the LPAs measured the temperatures which tested at 90.6 and 91.5 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in the office. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were observed in secure cabinets and inaccessible to clients. The facility had emergency kits in the garage for clients in care. There are no firearms, ammunition, pool or bodies of water in the facility. Overall, the facility is clean, and operational.
Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MISSION AT RAMONA
FACILITY NUMBER: 361880961
VISIT DATE: 10/10/2024
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Yards/Outside: LPAs observed one shaded patio, side gates with self-latching handles on the left side and right side of the house.

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: LPAs reviewed 4 client files for admission agreements, updated physician reports, and needs and services plans. LPAs also reviewed Licensee and staff files for First Aid/CPR certification, criminal record clearances, trainings, and health screenings. One (1) staff was missing current CPR training and a technical advisory was issued. P & I funds and medications were audited and appeared to be managed appropriately. The facility last conducted a disaster drill on September 6, 2024.

A deficiency were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, 9102TV were discussed and copies were provided to Administrator Andrew Gonzalez.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/10/2024 06:10 PM - It Cannot Be Edited


Created By: Lavette Farlow On 10/10/2024 at 05:38 PM
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: MISSION AT RAMONA
FACILITY NUMBER: 361880961

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by LPAs measured the temperatures which tested at 90.6 and 91.5 degrees fahrenheit; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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The Admisitrator was advised to conduct a total of 8 temperature check between today and tomorrow and submit a statement showing the corrected temperature measures to licensing by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


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