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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530213
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:57:08 PM


Document Has Been Signed on 09/20/2024 03:57 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:VILLAS AT SAN BERNARDINOFACILITY NUMBER:
365530213
ADMINISTRATOR:CARLTON, KENYAFACILITY TYPE:
740
ADDRESS:2985 N G STREETTELEPHONE:
(323) 475-1800
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92405
CAPACITY:144CENSUS: 92DATE:
09/20/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Kenys Carlton, AdministratorTIME COMPLETED:
04:00 PM
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On 09/20/2024 a 9:20AM, Licensing Program Analysts (LPAs) Renese Howell-Small and Melody Brown conducted an announced visit to the facility for the purpose of a Change of Ownership evaluation. LPAs Howell-Small and Brown met with Administrator Kenya Carlton. An initial application for change of ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 01/04/2024 for a total capacity of one hundred forty-four (144) . Fire clearance was granted on 05/16/2024 for 114 non-ambulatory and 30 bedridden residents, with a total capacity of 144. LPAs Howell-Small and Brown observed the following:

Structure:
Facility was a two-level with seventy-nine (79) resident bedrooms, seventy-nine (79) resident bathrooms and four (4) staff bathrooms, living room, dining area and kitchen. There was no attached car garage but have a parking lot on the south side of the facility.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control the entire facility.

Bedrooms:
Each resident bedrooms accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
The seventy-nine (79) resident bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. At 10:30 AM, LPAs tested the water temperatures in the resident bathrooms. LPAs verified water temperature was measured at 116 degrees Fahrenheit.

***CONTINUED ON LIC 809C***


SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-SmallTELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLAS AT SAN BERNARDINO
FACILITY NUMBER: 365530213
VISIT DATE: 09/20/2024
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***CONTINUED FROM LIC 809***
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPAs observed the stove to be operational. Refrigerator/freezer were in working condition. There is more than seven (7) days’ supply of non-perishable foods and more than two (2) days’ supply of perishable foods. There was adequate seating for meals for all residents. Laundry room with washer and dryer on both levels of the facility. Laundry detergents and cleaning supplies are stored in the chemical storage room.
Living/Family room:
There was a living/family room with adequate seating for all residents and a working TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the facility.
Yards/Outside:
Patio furniture for outdoor seating observed. Gates on both side of the facility. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the dining room and hallways. There was an Ombudsman poster and Let-Us-No poster and Personal RIghts observed.
General items:
Nineteen(19) fire extinguishers were charged and located throughout the facility. Smoke alarms and carbon monoxide detectors were tested and were observed to be in working order. Resident records were stored in a locked cabinet in the office room. First Aid kit with required components, and locked area for medication storage was observed. LPAs observed a facility phone and was operational as evidenced by LPAs dialing the number. The phone number designated for the facility is (909) 883-7703. There is enough Emergency water supply observed and the required 72-hour emergency food supply was observed from the regular food supply. Component III was completed on this day as well.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-SmallTELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLAS AT SAN BERNARDINO
FACILITY NUMBER: 365530213
VISIT DATE: 09/20/2024
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 ***CONTINUED FROM LIC 809C**

Additionally, LPAs observed facility to have required single entry point upon entering the facility. LPAs observed activities for the residents such as books and games.

The facility was evaluated in accordance with the CCR, Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of residents in care. Facility appears to be ready for licensure.

An exit interview was conducted, and a copy of this report, LIC809 and LIC9102 were reviewed and provided to Administrator Kenya Carlton.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-SmallTELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4