365530028-11-11-2023-56-AS-ACON-CXGT6P-20231111132727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530028
Report Date: 11/11/2023
Date Signed: 11/11/2023 01:27:35 PM

Document Has Been Signed on 11/11/2023 01:27 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:	MADRONA MANOR		FACILITY NUMBER:	365530028
ADMINISTRATOR:	KAUR, GULVARG		FACILITY TYPE:	740
ADDRESS:	821 EAST MADRONA STREET		TELEPHONE:	(909) 341-5084
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	6	CENSUS: 4	DATE:	11/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Gulvarg Kaur and Ashdeep Kaur, Administrators		TIME COMPLETED:	01:30 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, Amber Coleman, (LPA) arrived at the Madrona Manor facility unannounced to conduct the Annual Inspection. LPA rang the doorbell and was greeted by staff member, Esperanza Dura and Administrators Gulvarg Kaur and Ashdeep Kaur. LPA introduced self and stated purpose of the visit. LPA was granted entry, signed in and provided a space to work. The facility is a residential Home comprised of 5 bedrooms, 2 bathrooms, kitchen, dining room, den, backyard and attached garage. LPA conducted a general inspection, which include, but was not limited to the following: Physical Plant - The facility is approved for 6 residents. Five, (5) non-ambulatory residents and one, (1) bedridden resident. The facility maintains both a dementia and Bedridden Care Plan. LPA observed the facility maintained at a comfortable temperature. Pathways were free of clutter and obstructions. LPA inspected 4 resident rooms. Each room included all required furniture such as sufficient storage space, lighting, mattress with proper linens, night stands and seating. There are 2 bathrooms. Each bathroom was equipped with handrails, non-slip grip rugs, and adequate amounts of hand hygiene supplies. LPA observed 2 fully charged fire extinguishers; last inspected October 2023. The facility is also equipped with operable fire and carbon monoxide alarms. Signage such as personal rights, resident council, LET-US-KNOW and disaster/evacuation plans were posted in a common area. LPA confirmed that cleaning supplies, toxins, sharp objects, and other dangerous items were secure and kept inaccessible to clients. LPA measured the water temperature in the kitchen; which measured between 98 and 105 degrees F. There was a designated and secure storage space for client/staff files. Medications were secure in a hallway closet and secure refrigerator; inaccessible to unauthorized individuals. The facility maintains emergency food supplies and first aid kits readily available to those who may need it.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 11/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2023

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: MADRONA MANOR	FACILITY NUMBER: 365530028
	VISIT DATE: 11/11/2023

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Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care.. Facility offers a variety of foods to the residents in care with a posted food menu. Dishes, cups, and utensils were also stored properly.
Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. There are two staff members who also resident at the facility. LPA observed that staff members files included criminal record/fingerprint background clearance through the department.
Record Review: LPA reviewed 2 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 2 staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Administrator certificates both in good standing.

Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 11/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2023

LIC809 (FAS) - (06/04)

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