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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881321
Report Date: 07/11/2022
Date Signed: 07/11/2022 11:10:05 AM

Document Has Been Signed on 07/11/2022 11:10 AM - 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:CANYON VIEW HOMEFACILITY NUMBER:
361881321
ADMINISTRATOR:VERMANI, NITINFACILITY TYPE:
740
ADDRESS:9220 OLD RANCH RDTELEPHONE:
(909) 548-1769
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 5DATE:
07/11/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Nitin "Nick" Vermani TIME COMPLETED:
11:11 AM
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Licensing Program Analyst (LPA) Anna Bueno conducted a pre-licensing inspection . LPA identified herself to Administrator Nick Vermani 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 Rancho Cucamonga Fire Department on 6/2/2022 for 2 ambulatory, 3 non-ambulatory residents, and 1 bedridden. Administrator verified that the Fire Department tested fire alarms and carbon monoxide detectors during fire clearance inspection. The following were inspected:

LPA observed required postings including the ombudsman's poster, residents and council rights, and the facility's emergency/disaster phone numbers near the entry. There is a locked centralized area for medications, first aid supplies, and client and personnel 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 all resident bedrooms and observed all furniture and linens. LPA observed sufficient storage space and lighting. All bathroom appliances were operational and were equipped with grab bars and non-slip mats were observed.

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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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: CANYON VIEW HOME
FACILITY NUMBER: 361881321
VISIT DATE: 07/11/2022
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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 recent COMP III in the past and the current facility is in compliance.

The pre-licensing inspection is complete and there are no deficiencies. Applicant 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 Administrator Vermani at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC809 (FAS) - (06/04)
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