<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409910
Report Date: 06/21/2022
Date Signed: 06/21/2022 04:32:29 PM

Document Has Been Signed on 06/21/2022 04:32 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:VENTANA ARF-MONTE VERDEFACILITY NUMBER:
366409910
ADMINISTRATOR:HECTOR OBARFACILITY TYPE:
735
ADDRESS:1196 MONTE VERDE AVETELEPHONE:
(909) 985-7390
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 2DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Grace Obar - AdministratorTIME COMPLETED:
04:37 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) Anna Bueno made an unannounced annual required visit, with an emphasis on infection control. LPA met Administrator Grace Obar and two care providers who were advised of the nature of today's visit and LPA was granted entry to the facility. Administrator Obar verified that there are currently no active and/or suspected Covid-19 cases in this home.

LPA and Administrator toured the facility inside and out. The facility has no bodies of water. The facility has charged fire extinguishers, smoke alarms, and carbon monoxide detectors. Cleaning supplies and sharps were kept in locked cabinets. LPA observed at least two (2) days supply of perishable food items and seven (7) days supply of nonperishable food items. The client bedrooms had the required furniture and sufficient lighting. Facility had a supply of additional linen and hygiene items.

LPA observed one central entry point and routine symptom screening has been initiated at entry for all staff, clients, and visitors. LPA observed hand sanitizers and cleaning wipes throughout the facility. All clients have at least a 30 day supply of medications.

During the tour, LPA informed Licensee of licensing fees were due on 6/17/22 and are past due. This poses a potential safety risk for clients in care. LPA and Administrator were unable to inspect one of two staff room as Licensee did not have access to the room. This poses a potential safety risk for clients in care. Refer to LIC-809D for deficiencies cited.

Based on observations made during today’s inspection, deficiencies and technical advisories were issued. An exit interview was conducted where this report was discussed and a copy of this report was also provided to Administrator Obar at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 06/21/2022 04:32 PM - It Cannot Be Edited


Created By: Anna Bueno On 06/21/2022 at 03:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: VENTANA ARF-MONTE VERDE
FACILITY NUMBER: 366409910

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.185(e)

Fees for license or applications; use of revenues; collected; denial or forfeiture: (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the Licensee did not comply with the above regulation with the facility's past due licensing fees. LPA Bueno observed that the Licensee owes $1816.00 in licensing dues. This is a potential safety risk for all residents, as the license may be revoked
POC Due Date: 07/01/2022
Plan of Correction
1
2
3
4
Licensee shall submit proof of payment to Community Care Licensing of current dues no later than end of POC day.
Type B
Section Cited
CCR
80010(e)
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the Licensee did not comply with the section cited above as LPA was not able to inspect all staff rooms due to Licensee not having access to one of two room. This poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2022
Plan of Correction
1
2
3
4
Licensee shall submit evidence to Community Care Licensing that staff have acces to the above mentioned inaccessible staff room and that the room is not being used for any other purpose as such. Proof shall be submitted by the end of POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022


LIC809 (FAS) - (06/04)
Page: 5 of 5