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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881260
Report Date: 08/12/2023
Date Signed: 08/12/2023 02:05:03 PM

Document Has Been Signed on 08/12/2023 02:05 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:MISSION AT HARTZELLFACILITY NUMBER:
361881260
ADMINISTRATOR:PANGKEY,JOICE FFACILITY TYPE:
735
ADDRESS:943 HARTZELL AVETELEPHONE:
(909) 328-9790
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 4CENSUS: 4DATE:
08/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Fritzroy Campbell, LicenseeTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to complete a comprehensive annual inspection. LPA Nickolas met with Licensee Fritzroy Campbell and explained the purpose of the visit. Today’s inspection included a facility tour, records review, and interviews with staff and resident.

The facility is a five (5) bedroom and two (2) bathroom facility, with a kitchen/dining area, living area, and attached garage. Licensed capacity is four (4).

Physical Plant: The facility operates at the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility temperature is 75 degrees Fahrenheit. LPA inspected resident bedrooms; each room included required furniture such as mattresses, nightstands, storage space, chair(s), and sufficient lighting; bathrooms were clean, and appliances were functional. LPA Nickolas' observed adequate furniture and lighting throughout the facility. The hot water temperature tested within regulation between 111.0 and 116.2 degrees. The facility has operating smoke detectors and carbon monoxide alarms, which LPA Nickolas tested during the visit. LPA Nickolas observed personal rights posters, Licensing documents, and the disaster plan posted throughout the facility. LPA Nickolas observed that cleaning supplies, toxins, sharps, and other dangerous items are kept secure and inaccessible to residents in care. There was a designated storage space for client/staff files. LPA Nickolas observed medications locked and inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient in number for residents in care. The facility has a variety of food available for clients. Dishes, cups, and utensils were also appropriately stored.

Care & Supervision: The facility staff is sufficient in number for the care and supervision of residents in care. All staff members working in the facility have criminal record clearance through the department.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2023
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
, CA 92507
FACILITY NAME: MISSION AT HARTZELL
FACILITY NUMBER: 361881260
VISIT DATE: 08/12/2023
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Record Review: LPA Nickolas reviewed two (2) client files for admission agreements, updated physician reports, and needs and services plans. LPA Nickolas reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. P & I funds were counted and matched with the ledger. Medications were audited randomly and appeared to be dispensed appropriately by staff members.

No deficiencies were cited during this visit. LPA observed no apparent health and safety concerns at the time of visit. An exit interview was conducted where this report was discussed, and a copy of this report was provided to Campbell at the conclusion of the inspection.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2023
LIC809 (FAS) - (06/04)
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