361881276-6-22-2022-56-AS-ABUO-CFMRJ2-20220622130312

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881276
Report Date: 06/22/2022
Date Signed: 06/22/2022 01:03:25 PM

Document Has Been Signed on 06/22/2022 01:03 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 COMMONS		FACILITY NUMBER:	361881276
ADMINISTRATOR:	SORIANO, MARIAN		FACILITY TYPE:	740
ADDRESS:	10 TERRACINA BOULEVARD		TELEPHONE:	(909) 257-0721
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92373
CAPACITY:	59	CENSUS: 39	DATE:	06/22/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:04 AM
MET WITH:	Marian Soriano		TIME COMPLETED:	01:06 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) Anna Bueno conducted a pre-licensing inspection . LPA identified herself to Administrator Marian Soriano who was informed of the purpose of today's visit. The facility is currently licensed as a Residential Care Facility for the Elderly (RCFE) and the the pending application is for a change of ownership. The facility has been granted fire clearance by City of Redlands Fire Department on 4/20/2022 for 59 non-ambulatory residents, 10 of whom may be bedridden. LPA and ED toured the interior and exterior areas of the facility. Administrator and Maintenance director confirmed that fire alarms and carbon monoxide detectors were serviced during fire clearance inspection. The following were inspected: LPA observed required Licensing postings including the ombudsman's poster, complaint poster, residents and council rights, and the facility's emergency/disaster phone numbers near the entry. There was a locked centralized area for medications, first aid supplies, and client files. LPA inspected the facility kitchen and found it to be clean with sufficient food storage space. There is at least a 7 day supply of non-perishable foods, 2 day supply of perishable foods, and emergency food supplies. LPA observed storage areas for dangerous objects, cleaning supplies, and toxins were locked and inaccessible to residents. LPA inspected a sample of available resident units and found the rooms to have sufficient storage space and lighting. LPA observed call light systems in bathrooms and bedrooms. Bathroom appliances were operational and were equipped with grab bars. Administrator confirmed that non-slip mats are provided to the resident upon move in. *************CONTINUED ON LIC 809C*************

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MISSION COMMONS	FACILITY NUMBER: 361881276
	VISIT DATE: 06/22/2022

NARRATIVE

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LPA inspected the common areas. There were several activity areas and a dining area for residents. The outdoor space has shaded seating area for residents. The building appears to be in good repair and is equipped with functioning utilities. Overall, the facility appears to meeting operational compliance for residents in care and the surrounding remain clean and safe.

LPA waived COMP III due to the facility receiving a COMP III in the past. The pre-licensing inspection is complete and this facility has no deficiencies. Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed with and a copy was provided to Marian Soriano at the conclusion of the inspection.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

LIC809 (FAS) - (06/04)

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