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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881260
Report Date: 08/16/2024
Date Signed: 08/16/2024 03:22:01 PM

Document Has Been Signed on 08/16/2024 03:22 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:MISSION AT HARTZELLFACILITY NUMBER:
361881260
ADMINISTRATOR/
DIRECTOR:		PANGKEY,JOICE FFACILITY TYPE:
735
ADDRESS:943 HARTZELL AVETELEPHONE:
(909) 328-9790
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 4CENSUS: 3DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:42 PM
MET WITH:Camilla CampbellTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Magda Malcore and LaVette Farlow made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with Licensee, Camilla Campbell, and discussed the purpose of the visit. The facility is an Adult Residential facility with a license capacity of (4) and a current census (3). LPAs conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: The facility maintains an infection control plan, emergency disaster plan, and a current disaster drill record on file. The facility has 24 hour/7 days a week care staff. Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor activity space for clients in care. The facility is equipped with operating smoke/carbon monoxide alarms and telephone service. Client bedrooms were equipped with beds, bed linen, nightstands, chairs, storage space and sufficient lighting. Client bathroom toilets, hand washing basins and showers were operating in safe conditions. The hot water in client bathrooms tested at 112.5 degrees F. Sharps, disinfectants and cleaning supplies were store in a locked cabinet inaccessible to clients in care.

Food Service: The facility’s dining areas, kitchen, and dishware utilized by clients were maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MISSION AT HARTZELL
FACILITY NUMBER: 361881260
VISIT DATE: 08/16/2024
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Health Related Services: The facility maintains records of client medications and medications are centrally stored in a locked cabinet.

Personnel/Client Records: Staff records were reviewed for health screenings, criminal record clearances, and first aid/CPR training certification. Client records were reviewed for admission agreements, medical assessments, needs and service plans, and personal/incidental logs.

No deficiencies cited and a technical advisory was issued. An exit interview was conducted, where this report was discussed and a copy was provided to the Licensee, at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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