366402471-12-11-2023-56-AS-MMAE-CYERZ3-20231211122715

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366402471
Report Date: 12/11/2023
Date Signed: 12/11/2023 12:27:24 PM

Document Has Been Signed on 12/11/2023 12:27 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:	INGLESIDE LODGE		FACILITY NUMBER:	366402471
ADMINISTRATOR:	NEWELL, WILLIAM H.		FACILITY TYPE:	740
ADDRESS:	55747 MT. VIEW TRAIL		TELEPHONE:	(760) 228-1180
CITY:	YUCCA VALLEY	STATE: CA	ZIP CODE:	92284
CAPACITY:	15	CENSUS: 8	DATE:	12/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Nemessi Alanis		TIME COMPLETED:	12:35 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 Nemessi Alanis, Medtech and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (15) and a current census of (8) residents in care. The facility has a hospice waiver for (4) 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 is gated with no pools or other bodies of water. Outdoor shaded area is sufficient for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. LPA observed music playing, puzzles, books, and magazines in resident common areas. Resident’s bathrooms were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured between 105 to 107 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms, laundry equipment, and telephone service. The facility has sufficient bed linen, blankets, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, Community Care Licensing complaint poster, Ombudsman poster, disaster evacuation plan and emergency telephone numbers.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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: INGLESIDE LODGE	FACILITY NUMBER: 366402471
	VISIT DATE: 12/11/2023

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Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerators and freezers are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas.

Care & Supervision: Facility has 24-hour care staff. Staff working have criminal record clearances or exemptions through the Department.

Record Review: Staff files reviewed were observed to be complete. Resident files reviewed were observed to be complete. Administrator’s certification expires 11/29/2024. The facility conducted a disaster drill on 10/29/2023.

Medical Related Services: Facility has a complete first aid kit. All medication is centrally stored and kept in a locked cabinet.

Based on LPA observations and records review, no deficiencies were cited during today's visit.

An exit interview was conducted and copies of reports LIC809/LIC809-C/ LIC9102 were discussed and provided to Medtech Alanis 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: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC809 (FAS) - (06/04)

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