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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881034
Report Date: 01/15/2021
Date Signed: 01/19/2021 03:33:31 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:BROOKDALE LOMA LINDAFACILITY NUMBER:
361881034
ADMINISTRATOR:ADAMS, LUCINDAFACILITY TYPE:
740
ADDRESS:25585 VAN LEUVEN STREETTELEPHONE:
(909) 796-5421
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:220CENSUS: 122DATE:
01/15/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lucinda AdamsTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Christine Le conducted an announced tele-visit due to COVID-19 to the pending facility for the pre-licensing inspection. LPA met with applicant Lucinda Adams.

The pending application is for 220 non-ambulatory residents (of which 6 may be bedridden) in a Residential Care Facility for the Elderly. LPA toured the property inside and out. The following was observed, reviewed, and inspected: There are no bodies of water. The physical plant, in general, was in good repair. Buildings and grounds are free from hazards. Indoor and outdoor passageways are free of obstruction. There are charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. There is a locked area for medications and cleaning supplies. LPA observed a working telephone and basic laundry equipment. Resident bedrooms had the required bedding and furniture. Bedrooms had sufficient lighting. LPA observed grab bars and non-skid surfaces in the bathrooms. LPA observed the applicant measuring the hot water temperature in the bathrooms. The water temperature measured 109 degrees F. The facility had a sufficient amount of linen and hygiene items for the residents. In terms of the food supply, the facility had a sufficient amount of nonperishable and perishable food items. The food was kept in a safe and healthful manner. The facility menu was available for review. The freezer was 0 degrees F. The refrigerator was 45 degrees F. Dishes and glasses were in good condition. Trash cans have tight fitting covers. The facility had a designated area for staff and resident records. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. The facility was equipped with a complete first aid kit. There is adequate seating in the common areas. Facility had a supply of activities for the residents. LPA observed that the signal system located in the residents' room was functional. LPA also observed emergency lighting (e.g. flashlights).

No corrections are needed to be made. An exit interview was conducted via telephone and a copy of this report was provided to the applicant via email. Report with facility representative signature was obtained.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine LeTELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2021
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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