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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881067
Report Date: 03/11/2024
Date Signed: 03/11/2024 01:28:13 PM

Document Has Been Signed on 03/11/2024 01:28 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:REM CALIFORNIA LLC - MUIR MOUNTAINFACILITY NUMBER:
361881067
ADMINISTRATOR:RODRIGUEZ, CARINAFACILITY TYPE:
735
ADDRESS:3003 MUIR MOUNTAIN WAYTELEPHONE:
(909) 880-3444
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY: 4CENSUS: 4DATE:
03/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Michael Covarrubias, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility to conduct a required annual inspection. LPA identified herself to direct support professional (DSP) staff who was advised of the purpose of the visit. Staff phoned administrator Michael Covarrubias who arrived during the visit.

The facility is currently licensed as an Adult Residential Facility, vendored by the Inland Regional Center. The facility has capacity of four client, two of whom may be nonambulatory. Two staff and two clients are present at the facility during today's visit.

LPA Bueno and DSP Torres toured the interior and exterior of the facility. The facility has no bodies of water. There is a shaded area in the backyard for client use. LPA and DSP observed that side gate was unlocked and free of obstruction. The facility has working telephone for use and internet service accessible to all clients. The facility fire extinguisher was last inspected on 11/23/23 and were observed to be charged. DSP tested the carbon monoxide detector while Administrator Covarrubias tested the smoke detector - all units were found to be in working order. A locked centralized medication cart was observed while client and staff files and facility records are kept secured. Sharps, toxins, and cleaning agents are in locked closets and cabinets.

The following were observed of the physical plant:
Client Bedrooms and Bathroom: LPA Bueno and DSP Torres observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. The facility had a supply of additional linens and towels. LPA and DSP observed bathrooms were kept in sanitary conditions and provisions for hygiene items are available.
Kitchen and Dining Areas: LPA and DSP inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. LPA and DSP inspected food provisions and found a 2-day supply of perishable food and 7-day supply of non-perishable food items. LPA reviewed the facility menu.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Fannell
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: REM CALIFORNIA LLC - MUIR MOUNTAIN
FACILITY NUMBER: 361881067
VISIT DATE: 03/11/2024
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Common (living/activity) areas: LPA and DSPs Torres and Terry observed adequate seating in the common areas. LPA observed activities stored around the kitchen area. Calendar of activities is posted on the refrigerator.

The following records were inspected:
Client Records: LPA Bueno inspected four client files and found all to have the required documentation, including but not limited to, placement and admissions agreement, current Individual Program Plan (IPP), and and Individual Service Plan (ISP).
Staff Records: LPA reviewed six staff files and found health screening report, and unexpired CPR and credentials. Administrator certificate is current. LPA reviewed training and disaster drill logs.
Centralized Medication: LPA reviewed client medication administration records. LPA and DSP Terry observed scheduled medications appear to be administered as prescribed.

During the tour, LPA observed that Client 1 is utilizing the facility family room as their bedroom. This poses an immediate health and safety risk to clients in care. Refer to LIC 809D for deficiency cited.

Administrator Covarrubias provided an updated facility sketch to LPA during this visit and Administrator will be sending the sketch to the Regional Office and to the local Fire Inspector's office. An exit interview was conducted where a copy of this entire report and appeal rights were provided to Administrator at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Fannell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/11/2024 01:28 PM - It Cannot Be Edited


Created By: Anna Fannell On 03/11/2024 at 12:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: REM CALIFORNIA LLC - MUIR MOUNTAIN
FACILITY NUMBER: 361881067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85087(a)(3)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and staff interviews, the licensee did not comply with the section cited above as Client 1 is utilizing the family room as their bedroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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Licensee shall relocate Client 1 to a client room approved by the local Fire Inspector. Licensee shall provide proof of correction no later than end of POC day.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Anna Fannell
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024


LIC809 (FAS) - (06/04)
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