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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881019
Report Date: 02/24/2021
Date Signed: 02/24/2021 04:23:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WILDWOOD CANYON VILLAFACILITY NUMBER:
361881019
ADMINISTRATOR:OSORIO, JULIUSFACILITY TYPE:
740
ADDRESS:33951 COLORADO STTELEPHONE:
(909) 446-0405
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY:130CENSUS: 53DATE:
02/24/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Julius OsorioTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Stephanie Williams conducted a pre-licensing inspection via video-conferencing application due to the COVID-19 pandemic. LPA identified herself and conducted the tele-visit with Administrator, Julius Osorio.

The pending application is for a change of ownership in a Residential Care Facility for the Elderly (RCFE). The facility has been granted a fire clearance for 130 bedridden residents by the City of Yucaipa Fire Prevention Department on 1/8/2021. The facility is approved for delayed egress and secured locked perimeter. There is a memory care unit within the facility. LPA toured the interior and exterior area of the facility. The following was inspected:

LPA inspected a sample of resident bedrooms; bedrooms have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, and lighting. LPA observed call light systems in the bedrooms. LPA inspected a sample of resident bathrooms; bathroom appliances were operating in safe and sanitary conditions and were equipped with non-skid floors and grab bars. LPA inspected the kitchen and found it to be clean with sufficient food storage space. It appeared there was a 7-day supply of non-perishable foods, 2-day supply of perishable foods, and emergency food supplies. LPA inspected storage areas and found that dangerous objects, cleaning supplies, and toxins were locked and inaccessible to residents. Administrator confirmed that fire alarms, fire extinguishers, and carbon monoxide detectors were serviced during fire clearance inspection. LPA inspected the common areas; there were several large activity areas and a dining area for residents. LPA observed required postings including the ombudsman's poster, residents council rights, and the facility's emergency/disaster plan. There was a locked and centralized storage area for medications and first aid supplies. The facility had a designated area for client files and staff files. The facility had a working telephone for resident use. LPA inspected the outdoor space; there was a shaded seating area for residents. The building appears to be in good repair and is equipped with functioning utilities. Overall, the facility appears to be operable for residents in conditions that are clean and safe.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WILDWOOD CANYON VILLA
FACILITY NUMBER: 361881019
VISIT DATE: 02/24/2021
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Pre-Licensing is complete and this facility has no deficiencies. LPA determined to waive COMP III presentation due to the facility completing COMP III in the past. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy was provided to Osorio via email.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021
LIC809 (FAS) - (06/04)
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