365530075-1-19-2024-56-AS-MMAE-CZMVS2-20240119154050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530075
Report Date: 01/19/2024
Date Signed: 01/19/2024 03:41:01 PM

Document Has Been Signed on 01/19/2024 03:41 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:	CANYON VIEW COUNTRY HOME		FACILITY NUMBER:	365530075
ADMINISTRATOR:	CREIGHTON, IREN		FACILITY TYPE:	740
ADDRESS:	418 HASTINGS ST.		TELEPHONE:	(909) 548-1769
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92373
CAPACITY:	6	CENSUS: 6	DATE:	01/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Iren Creighton, Administrator		TIME COMPLETED:	03:45 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) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Iren Creighton, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6) and a current census of (6) residents in care. The facility has a hospice waiver for (6) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. Outdoor backyard is sufficient for resident activities and is enclosed with self-latching gates. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathrooms were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured 105 to 106 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms, signal systems and telephone service. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, resident's personal rights, disaster evacuation plan and emergency telephone numbers. Care & Supervision: Facility has (24) hour/(7) days a week care staff. Staff working have criminal record clearances or exemptions through the Department.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

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: CANYON VIEW COUNTRY HOME	FACILITY NUMBER: 365530075
	VISIT DATE: 01/19/2024

NARRATIVE

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Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. Sharps, pesticides and other cleaning solutions were kept locked and stored away from food areas.

Record Review: Staff files reviewed at random were observed to be complete. Resident files reviewed at random were observed to be complete. Administrator’s certification expires on 10/29/24.

Medical Related Services: The facility has a complete first aid kit. Resident's medication is centrally stored and kept in a locked cabinet.

Based on observations and record review, no deficiencies were cited during today’s visit.

An exit interview was conducted where the Licensing reports were discussed and copies were provided to the Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC809 (FAS) - (06/04)

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