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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366410618
Report Date: 10/27/2023
Date Signed: 10/27/2023 11:13:56 AM

Document Has Been Signed on 10/27/2023 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:OHIO LANE MANORFACILITY NUMBER:
366410618
ADMINISTRATOR:HANNER, CYNTHIAFACILITY TYPE:
735
ADDRESS:7122 OHIO LANETELEPHONE:
(909) 823-7122
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 0DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kristin Ridings, Administrator TIME COMPLETED:
11:15 AM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Ohio Lane Manor, Adult Residential Facility unannounced to conduct the Annual Inspection. LPA was greeted and granted entry by, Administrator, Kristin Ridings. LPA was provided space to work and then accompanied on a walk through of the facility. LPA was informed that residents were at their day programs at time of visit. There are 3 residents in care at this time.

The facility is comprised of 5 Bedrooms, (2 staff/family rooms & 3 Resident Rooms) 3 Bathrooms, Living Room, Dining Area, Den, Kitchen, Laundry Room, backyard and attached garage. The facility is an Adult Residential Facility (ARF) maintains vendorship with the Inland Regional Center at level 2.

LPA was provided a tour of the facility to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is licensed for 4 ambulatory adult residents. The facility is operating in the capacity approved by Community Care Licensing (CCL). Pathways interior and exterior were unobstructed. The facility is maintained at a comfortable 71 degrees in temperature. fire/smoke detector and carbon monoxide alarms were tested and found functional during the visit. Administrator reports fire drills and house meetings are conducted on a monthly basis. Earthquake Drills are conducted every six months. Last drill conducted March 2023.

LPA observed resident rooms, each room included a mattresses with fitted linens, sufficient lighting, storage and seating; as regulated. Additionally, all rooms appeared neat and orderly. LPA also observed additional lighting throughout the facility. LPA observed furniture in good repair to provide adequate seating in both the living and dining rooms. The hot water temperature tested and ranged between 100 and 105 degrees. LPA observed posters for resident rights, Long Term Care Ombudsman, licensing information, resident roster, the Please see LIC809-C

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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: OHIO LANE MANOR
FACILITY NUMBER: 366410618
VISIT DATE: 10/27/2023
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food menu, LET-US-KNOW and Infection Control posted in a common area of the facility. The facility's sharp objects are kept in the kitchen in a secure drawer. Chemicals/cleaning supplies were observed secure and inaccessible to residents. The resident's medications and records are stored securely. Resident, Facility and Staff files were also found to be kept secure.

Food Service: LPA observed a pantry and cabinets well stocked with canned goods, snacks and dry foods in good standing. LPA observed the facility refrigerators and freezers stocked with adequate amounts of milk, eggs, break, water, meats, frozen meals, and juices. Sufficient amounts of both perishable and non-perishable food for the number of residents in care. LPA also observed adequate amounts of Dishes, cups, and utensils properly stored and in adequate amounts. LPA observed a fully charged fire extinguisher, last inspected March 2023. Emergency Supplies of food, water, batteries, personal protective equipment (infection control) were located secure in the garage.



Records: LPA reviewed three, (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed that one, (1) out of three, (3) physician reports was outdated. LPA also reviewed three, (3) staff files for First Aid/CPR certification, criminal record/fingerprint clearance, training, and health screenings. Each staff file was found to have all required licensing documents.

Overall, LPA observed that the facility is orderly, in good repair, and operating in safe conditions for residents in care.

Based on observations, interviews and record reviews, a technical violation is being issued to address the client medical assessment. No deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Facility Representative; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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