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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530144
Report Date: 11/06/2023
Date Signed: 11/06/2023 12:05:46 PM

Document Has Been Signed on 11/06/2023 12:05 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:MEADOW VIEW SENIOR CAREFACILITY NUMBER:
365530144
ADMINISTRATOR:MANALO, MELANYFACILITY TYPE:
740
ADDRESS:1585 W. MCWETHY ST.TELEPHONE:
(562) 455-6491
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 0DATE:
11/06/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Melany Manalo, LicenseeTIME COMPLETED:
12:10 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Meadow View Senior Care facility for a scheduled visit to conduct the Pre-Licensing Inspection. LPA rang the doorbell introduced self and stated purpose of the visit. LPA was greeted and granted entry by Melany Manalo, Licensee, Jay De Leon, Facility Manager and Caregiver, Geline De Leon. LPA was provided a space to set up and work, then provided a tour of the facility inside and out. LPA observed the following:

Application: The application is for Residential Care Facility for the Elderly, (RCFE) submitted on 5/15/23. Fire clearance has been granted for two (2) non-ambulatory and four, (4) bedridden residents. Fire clearance and inspection completed and approved on 9/14/23

Buildings and Grounds: The facility is comprised of 5 bedrooms, 3 bathrooms, kitchen, dining room, living room, attached 2 car garage and backyard. Pathways interior and exterior free of clutter and unobstructed. In the hallway is a station for the washer and dryer. Cabinetry above the washer and dryer provides a secure space for laundry detergent and other chemicals to be housed. LPA observed combination smoke/fire and carbon monoxide alarms throughout the facility. 2 fully charged fire extinguishers - purchased July 2023.
Hallway closets contained extra linens and towels for future residents. Infection control station was observed upon entry to facility. It contained a sign in sheet, hand hygiene supplies, thermometer and PPE.

Resident Rooms - each room included a regulated mattress, bed linens, seating, trash bins, intact window screens and sufficient lighting. Each room also included a floor plan with the evacuation route highlighted. 3 resident rooms contain a doorway entry into the facility's backyard. All three doorways included a cement ramp and wood railing for additional support and added safety for each resident entering or departing entry way. Facility Manager reports that he will be installing door alarms on each of the doors to notify staff when a resident has stepped out into the backyard for safety purposes.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2023
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: MEADOW VIEW SENIOR CARE
FACILITY NUMBER: 365530144
VISIT DATE: 11/06/2023
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Bathrooms - There are 3 bathrooms, LPA observed each bathroom to have railing inside the showers and non-slip grip mats on the floor. Two of the bathrooms include a walk in shower. One of the bedrooms' includes an attached bathroom.
Food Service/Kitchen: LPA observed the facility kitchen. Appliances observed to be functional and in good repair. Silverware, dishes and cups in adequate amounts for the number approved residents. The designated area for sharps and additional cleaning supplies is a secure kitchen cabinet. The kitchen pantry is also where the facility's first aid kit and emergency food supplies are maintained. The water temperature was tested and measured between 109-115 within regulatory limits.
Living Room- included adequate seating, a television and activities for residents. Activities such as board games, connect four, checkers/chess, bingo observed in the living room, accessible for resident use. The facility maintains an internet connection and working landline phone for its residents.
Storage and Supplies: Medications, Medications, Records, Staff/Resident files are designated to be stored in the facility office (staff room)
Backyard: included adequate seating and spacing for activities. During the walk through LPA observed a large pile of landscaping materials near the perimeter gate. Also variable sizes of wood pieces laying about a pathway. Licensee reports that these items are to be removed by the contractor within the next 2 weeks.
Exterior pathways were clear and unobstructed. There are no pools or other bodies of water located on premises. Administrator and Licensee report there are no weapons or ammunition kept in the facility.
Overall, the facility is clean, in good repair, and operating in safe conditions.


Forms: The following forms were observed to be posted in a common area: Emergency Disaster Plan (LIC 610D), Personal Rights, Resident Counsel, Facility Sketch/Evacuation Plans (in each room), LET-US-KNOW in each room. Labor laws and licensing information.

No deficiencies were observed during inspection. Licensee agrees to have the materials removed within the following 2 weeks. LPA will inform the Centralized Applications Bureau the home is ready to be licensed. An exit interview was conducted. This report was reviewed, discussed then provided to Melany Manalo
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC809 (FAS) - (06/04)
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