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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530047
Report Date: 01/09/2024
Date Signed: 01/09/2024 11:19:04 AM

Document Has Been Signed on 01/09/2024 11:19 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BANYAN HOUSEFACILITY NUMBER:
365530047
ADMINISTRATOR:ESTELLE, VICKIFACILITY TYPE:
735
ADDRESS:18326 BANYAN AVETELEPHONE:
(909) 587-2431
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 6CENSUS: 4DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Leslie Hodges, House ManagerTIME COMPLETED:
11:20 AM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Banyan House, Adult Residential Facility unannounced to conduct an Annual Inspection. LPA introduced self and stated purpose of the visit. LPA met with Staff Members, Manual Cordoba and Leslie Hodges who granted LPA entry inside facility. Staff contacted Administrator, Vicki Estelle, who arrived later during the visit.

LPA was accompanied by Staff Member, Leslie to conduct a tour of the facility, inside and outside, and observed the following:

Facility: The Facility is approved for six (6) ambulatory adults, ages 18 -59. LPA observed that the facility is operating in the capacity and conditions approved by Community Care Licensing (CCL).
Physical Plant: LPA observed the facility to be maintained at a comfortable temperature. Interior and exterior pathways were free of clutter and obstructions. LPA observed 2 and a half bathrooms. Each bathroom included operable appliances, adequate amounts paper supplies, non-slip materials and handrails. LPA observed extra hygiene supplies, personal protective equipment, (PPE) and linens are kept secure in hallway closets. Additionally, LPA observed chemicals, tools and resident medications were also kept secure in a hallway closet. Resident rooms each included appropriate lighting, seating, bed and linens and storage for residents in care. Various light sources such as lamps and night-lights were observed throughout the facility. Fire extinguishers, (2) were observed fully charged and last inspected September 2023. LPA was informed the facility conducts fire and earthquake drills every six months. Last drill conducted on 11/2/2023.

Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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: BANYAN HOUSE
FACILITY NUMBER: 365530047
VISIT DATE: 01/09/2024
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Food Service: LPA observed the facility's kitchen. LPA was shown the non-perishable food supply was sufficient in amounts and in good standing. LPA observed the facility's refrigerators and freezers to include food items such as milk, bread, fresh fruits and vegetable and beverages also sufficient in amounts for the number of residents in care. LPA measured the water temperature and observed that it ranged between 110- 134 degrees. Staff agreed to post a caution sign near faucet to use caution when in use.
Care & Supervision: Facility has two staff members who resident on facility grounds which is adequate for the number of residents in care.
Record Review and Resident/Staff Files: LPA reviewed records for all four (4) residents current in care of the facility. One out of four residents were missing a Physician's Report. With the one exception, resident records are complete with updated physician reports and Needs and Services Plans. LPA reviewed, three, (3) staff files; and confirmed that staff records reflect current CPR/First Aid Certification and Criminal Record Clearance. The Administrator's Administrator Certificate in good standing.
Administration: Facility Sketch/Disaster Plan, Emergency contact information, Ombudsman poster, Resident Rights, House Rules, Infection Control, Administrator Certificate, and facility license are posted in the hallway of the facility.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and secure in a hall closet in the office. LPA reviewed the residents' medications list and compared it to the facility's Medication Administration Report (MARs). LPA made no observations of medication errors.

Based on observations, record reviews and interviews, no deficiencies were cited during this inspection. Technical Violations are being issued to address the above mentioned concerns. Exit interview conducted, this report was reviewed, discussed and copy provided to Administrator/Licensee Vicki Estelle.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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