361881048-12-27-2023-56-AS-ACON-CYWTQW-20231227135638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881048
Report Date: 12/27/2023
Date Signed: 12/27/2023 01:56:42 PM

Document Has Been Signed on 12/27/2023 01:56 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:	AQUA RIDGE OF MONTCLAIR		FACILITY NUMBER:	361881048
ADMINISTRATOR:	MONIQUE DEL JUNCO		FACILITY TYPE:	740
ADDRESS:	9631 MONTE VISTA AVE		TELEPHONE:	(909) 483-2782
CITY:	MONTCLAIR	STATE: CA	ZIP CODE:	91763
CAPACITY:	115	CENSUS: 65	DATE:	12/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:			TIME COMPLETED:	02:00 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, Amber Coleman, (LPA) arrived at the Aqua Ridge of Montclair, Residential Care Facility for the Elderly, (RCFE) unannounced to conduct the Annual Inspection. LPA was greeted by Business Office Director, Diana Gonzalez and asked to sign in while the Executive Director was contacted and made aware of LPA visit. During today's visit, LPA was accompanied on a tour of the facility's interior and exterior, completed resident and staff interviews and reviewed facility records. LPA observed the following: Facility: The facility is currently licensed as RCFE / Dementia Care and approved for 115 residents. Sixty, (60) and up. One hundred three residents may be non-ambulatory and 12 residents maybe bedridden. Hospice Waiver Approval for 12 Residents. LPA observed that the facility is operating in the capacity and conditions approved by Community Care Licensing (CCL). Physical Plant: During the tour of the facility, LPA observed that the facility was maintained at a comfortable temperature appropriate for outside weather conditions. Bathroom water temperature measured within regulatory limits. Bathroom appliances such as toilets, sinks, bathtubs and showers were in operable conditions. Housekeepers maintain the cleaning supplies and linens securely; Also in adequate amounts for the number of residents in care. LPA observed that each resident room, hallways and areas throughout the facility were well lit with a variety of lighting fixtures; to ensure safety of residents in care. The facility included smoke/fire alarms and carbon monoxide detectors throughout the facility. According to staff and documentation, the last fire/disaster drill was conducted on 10/24/23 no concerns listed. All fire extinguishers located throughout facility were last inspected August 2023. Please see LIC9099-C

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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: AQUA RIDGE OF MONTCLAIR	FACILITY NUMBER: 361881048
	VISIT DATE: 12/27/2023

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Food Service: LPA observed the facility's dining room provided adequate space, seating and lighting. LPA met with Culinary Director, Chris Riley who toured the facility kitchen. LPA observed that the facility's food supply of non-perishable and perishable food items is adequate for the amount of residents in care. All food items were in proper storage and in good standing. The facility also maintains a separate pantry of emergency food supply. The amount also adequate for the number of residents in care. Food menus are maintained on each resident dining table.

Care & Supervision: LPA observed sufficient and attentive care staff present during the visit. All toxic and dangerous items are kept secure and inaccessible to unauthorized individuals. Resident and Staff Records are kept secure among staff and in their offices.

Record Reviews of Staff/Resident Files: LPA reviewed fifteen, (15) resident files and found that all 15 records were complete with update physician reports, admissions agreements and needs and services plans. LPA reviewed ten, (10) staff files for current CPR/First Aid Certifications and Criminal Record Clearances. All documents were accounted for per regulation.

Administration: Evacuation/Disaster Plan, Long Term Care Ombudsman Poster, Administrator Certificate, and Facility License are posted in prominent places of the facility. Emergency Disaster Plan is current.

Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and secure in the Medication Technician's Office. LPA reviewed Centrally Stored Medication Logs. LPA did not observe any medication errors.

Based on observations, interviews and records; no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Jessica Sanchez signature acknowledges understanding and receipt of report and attachments.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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