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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530261
Report Date: 09/30/2024
Date Signed: 09/30/2024 11:13:59 AM

Document Has Been Signed on 09/30/2024 11:13 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:SIERRA VISTAFACILITY NUMBER:
365530261
ADMINISTRATOR/
DIRECTOR:		MEJIA, KIMBERLYFACILITY TYPE:
740
ADDRESS:13815 RODEO DRIVETELEPHONE:
(760) 243-2271
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 99CENSUS: 0DATE:
09/30/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator - Kimberely MejiaTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analysts (LPAs) Mary Rico and Eldin Serrano conducted an announced visit to complete a pre-licensing inspection and component III. LPA met with Administrator Kimberly Mejia. The pending application is for a change of ownership for a Residential Care Facility for the Elderly (RCFE). The approved fire clearance granted for (15) ambulatory, (64) non-ambulatory and (20) bedridden residents on 7/17/2024.
The facility has (50) resident's bedrooms, (44) bathrooms. There is a kitchen, a lobby area, a dining area, a living room, a laundry room, and a courtyard. The following were inspected:

The interior and exterior were toured of the pending facility. Overall, the pending facility is clean and in good condition. LPAs observed all bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, showers have grab bars and non-skid mats. The hot water temperature in the kitchen was measured at 109 degrees Fahrenheit. LPAs observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer temperatures are maintained at appropriate temperatures. All appliances are clean and operating properly. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present including a First Aid Manual.

LPAs observed an adequate supply of recreation and leisure items and activities. The courtyard space is suitable for resident use that includes a covered patio with a table and chairs. LPAs observed the fire extinguishers to be recently serviced and completely charged. Smoke alarms and carbon monoxide detectors are present and functional. Medications will be centrally stored and secured in a locked cabinet. All hazardous materials such as, cleaning, and disinfecting supplies, knives and other sharps are locked and inaccessible to residents. All required forms are posted in a common area.

Pre-Licensing Inspection is complete and has no deficiencies. No corrections need to be made.
An exit interview was conducted where this report was discussed and provided to Administrator Kimberley Mejia.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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