366406690-6-14-2023-56-AS-MMAE-CSSSCM-20230614134545

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366406690
Report Date: 06/14/2023
Date Signed: 06/14/2023 01:45:49 PM

Document Has Been Signed on 06/14/2023 01:45 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:	MOUNTAIN OF PROMISE		FACILITY NUMBER:	366406690
ADMINISTRATOR:	KAY F. NILES		FACILITY TYPE:	775
ADDRESS:	1381 MANZANITA WAY		TELEPHONE:	(909) 337-0219
CITY:	DEER LODGE PARK	STATE: CA	ZIP CODE:	92352
CAPACITY: 15		CENSUS: 15	DATE:	06/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Cathy Yturralde, Office Manager		TIME COMPLETED:	01:45 PM

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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required annual visit to the facility. LPA met with Cathy Yturralde, Office Manager and discussed the purpose of the visit.

The facility is an Adult Day Program and operates at a 3:1 staff to client ratio. LPA observed no clients as the time of the visit. LPA conducted an overall inspection, which included, but was not limited to the following:

Interior: The inside of the facility was toured; the facility was clean and in good repair. The temperature in the facility was at a comfortable temperature. Facility passageways are clear and free of obstructions. Facility has sufficient space and furniture in good repair for client activities LPA inspected client bathrooms; bathroom appliances were operating in good and sanitary conditions. The hot water temperature tested within regulation at 110 degrees F. LPA inspected facility kitchen which was clean and free of odors. Snacks were accessible to clients and stored in a healthful manner. Knives, cleaning supplies, and toxins were kept locked and inaccessible to clients. Facility smoke detector and carbon monoxide alarm were functioning properly. Fire extinguisher is fully charged. Emergency disaster plan and emergency contact information were posted in the common area. The last disaster drill was conducted on 6/7/23. Facility has a first aid kit and sufficient emergency supplies.

Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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: MOUNTAIN OF PROMISE	FACILITY NUMBER: 366406690
	VISIT DATE: 06/14/2023

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Records Review: LPA reviewed (3) staff records for criminal record clearance, first aid/CPR training, and health screening. LPA reviewed (3) client records for admissions’ agreements, physician reports, and needs and services plans, Individual Program Plan (IPP's). No client medications are stored in the facility.
No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was provided to the Office Manager at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

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