361881048-10-4-2021-18-AS-AGOG-C7BQ6Z-20210929115422

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881048
Report Date: 09/29/2021
Date Signed: 10/04/2021 07:42:06 AM

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:	AQUA RIDGE OF MONTCLAIR		FACILITY NUMBER:	361881048
ADMINISTRATOR:	AMIRI, AZIZ		FACILITY TYPE:	740
ADDRESS:	9631 MONTE VISTA AVE		TELEPHONE:	(909) 483-2782
CITY:	MONTCLAIR	STATE: CA	ZIP CODE:	91763
CAPACITY:	115	CENSUS: 0	DATE:	09/29/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Torrie Tortorelli,Vice President of Operations Melissa Sumling, Resident Services Director		TIME COMPLETED:	12:00 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) Amy Goldenberg conducted an announced visit to the facility for purpose of a Pre-licensing evaluation. An initial application to operate a Residential Care for the Elderly was submitted to the Central Applications Unit (CAU) on 10/13/2020. Fire clearance was granted 8/10/2021 for 103 non-ambulatory residents and 12 bedridden residents to remain on the first floor only. LPA met with Torrie Tortorelli, Vice President of Operations LPA Goldenberg observed the following: Structure: The facility is new construction. It is a two story building and has rooms to accommodate capacity of 115. Heating/Cooling System: Central heating and air conditioning systems. Each unit has their own control. Bedrooms: Bedroom was adequately furnished with a bed, chair, large closet, appropriate linen, and adequate lighting. The facility will provide furnishings if needed, residents will be encouraged to personalize the units. Bathrooms: Bathrooms have a toilet, wash basin, and shower. An adequate supply of towels, toilet paper, and toiletries have been made available for incoming residents. Water temperature measured 109 degrees Fahrenheit.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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: AQUA RIDGE OF MONTCLAIR	FACILITY NUMBER: 361881048
	VISIT DATE: 09/29/2021

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
26
27
28
29
30
31
32

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans are observed. Cleaning supplies and knives/sharp instruments are secured inaccessible to residents. There is adequate room for food storage. Refrigerator/freezer are in working condition. There is adequate seating for meals.

Living/Family room: Furnished with safe and ample seating and furnishings. All items are brand new.

Yards/Outside: The back was completed with umbrellas for providing shade. The facility has seating available for residents use. There were no obstructions to the walkway, entrances or exits. There were no bodies of water observed anywhere on the property.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster and clients rights are posted. Emergency exit maps are posted throughout the facility.

General items: The fire/smoke/carbon monoxide alarm system were approved during the fire inspection. Water and electricity is turned on. Delayed egress system is in place and tested functional.

COMP III review was conducted during this visit.

There are no identified potential hazards as a result of this visit. This facility physical plant is prepared for licensure at this time.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2