361881034-12-19-2023-56-AS-MMAE-CYNTQB-20231219135540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881034
Report Date: 12/19/2023
Date Signed: 12/19/2023 01:55:49 PM

Document Has Been Signed on 12/19/2023 01:55 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:	BROOKDALE LOMA LINDA		FACILITY NUMBER:	361881034
ADMINISTRATOR:	LUJAN, MARITZA		FACILITY TYPE:	740
ADDRESS:	25585 VAN LEUVEN STREET		TELEPHONE:	(909) 796-5421
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	220	CENSUS: 110	DATE:	12/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Maritza Lujan, Executive Director		TIME COMPLETED:	02:05 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 Maritza Lujan, Executive Director, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (220) and a current census of (110) residents in care. The facility has a hospice waiver for (20) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. The facility has sufficient indoor and outdoor space for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has operating carbon monoxide alarms, signal system, and telephone service. The (6) resident bathrooms inspected were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured between 105 and 112 degrees F. The (6) resident bedrooms inspected had sufficient bed linen, lighting and furniture in good repair. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, facility license, resident's personal rights, and disaster evacuation plan and emergency telephone numbers. Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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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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: BROOKDALE LOMA LINDA	FACILITY NUMBER: 361881034
	VISIT DATE: 12/19/2023

NARRATIVE

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Pesticides and other cleaning solutions were kept locked and stored away from food areas.
Care & Supervision: Facility has 24-hour/ 7-days a week care staff.
Record Review: (5) staff files reviewed were observed to be complete and included criminal record clearances or exemptions through the Department. (5) resident files reviewed were observed to be complete. Last emergency drill was conducted on 11/18/23. The Executive Director's certification expires on 4/12/2024.
Medical Related Services: All medication is centrally stored and kept locked in the medication room.

Based on LPA observations and record review, no deficiencies were cited during today’s visit.

An exit interview was conducted where reports LIC809/LIC809-C/LIC9102 were discussed and a copies were provided to the Executive Director 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: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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