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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408080
Report Date: 10/21/2022
Date Signed: 10/21/2022 11:54:40 AM


Document Has Been Signed on 10/21/2022 11:54 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:MULBERRY MANORFACILITY NUMBER:
366408080
ADMINISTRATOR:ERIKA JOY CASTANEDAFACILITY TYPE:
740
ADDRESS:1013 N. MULBERRY AVETELEPHONE:
(909) 421-4427
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:4CENSUS: 3DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Arnold Castaneda-LicenseeTIME COMPLETED:
12:03 PM
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Licensing Program Analysts (LPAs) Ryan Gardner and Victoria Chitgian made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic.

LPAs met with Licensee Arnold Castaneda and were granted entry to the facility. At the time of the visit there were three (3) staff, and two (2) residents present. One (1) resident was away at the time of the visit.

LPAs toured the facility inside and out and went over COVID-19 best practices for infection control and prevention with Arnold Castaneda. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating residents and properly caring for residents with COVID-19 positive results and/or exposures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The entrance of the facility has a check in process for staff and visitors that includes a temperature and symptom check. The facility has hand sanitizer available, and the bathrooms were stocked with hand soap and paper towels. Postings were seen throughout the facility for proper cough etiquette, proper hand washing procedure, and social distancing guidelines. LPAs requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in the garage. The facility has a supply of PPE including gloves, gowns, disinfectant, surgical masks, N95 masks, and hand sanitizer. All staff and residents are practicing COVID-19 precautions, which minimize the risk of them contracting COVID-19.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Licensee Arnold Castaneda.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
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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