366413049-4-11-2024-56-AS-MECA-D48QJU-20240411121319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366413049
Report Date: 04/11/2024
Date Signed: 04/11/2024 12:13:29 PM

Document Has Been Signed on 04/11/2024 12:13 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:	MAEMAR MANOR		FACILITY NUMBER:	366413049
ADMINISTRATOR:	MARIA LUCAS		FACILITY TYPE:	740
ADDRESS:	14262 LA MESA RD		TELEPHONE:	(760) 220-8322
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY:	6	CENSUS: 6	DATE:	04/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:34 AM
MET WITH:	Maria Lucas-Administrator		TIME COMPLETED:	12:23 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	On 4/11/24, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Maria Lucas and introduced self and stated purpose of the visit. LPA was informed that there are currently 6 residents in care who are in the facility. The facility has 6 bedrooms, 3 bathrooms, kitchen, dining area, living room, family room, laundry room, medication room, attached garage, and backyard with a shed. LPA completed a walk through of facility, and review of records. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA observed a urinal inside a resident's bedroom with urine inside and not discarded. Deficiency issued. LPA inspected resident bathrooms; bathroom were clean and appliances were found functional. Water temperatures tested at 110.1 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. LPA observed a broken bedroom closet; medication accessible in the kitchen drawer, refrigerator and residents bedrooms; knives in kitchen sink and drawers; chemicals underneath the kitchen sink and inside the accessible laundry room; and dust accumulated in residents bedrooms. Deficiency issued. There was a designated storage space for resident/staff files and medication. There is no swimming pool, bodies of water, guns or ammunition in the facility. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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 6

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: MAEMAR MANOR	FACILITY NUMBER: 366413049
	VISIT DATE: 04/11/2024

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
26
27
28
29
30
31
32

Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard, and 1 shed used for storage. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed incomplete resident records: outdated physician's reports and missing personal rights forms. Deficiency issued. LPA observed a bedridden resident record without an approved fire clearance. Deficiency with civil penalty issued. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed the emergency disaster plan not reviewed/outdated since 04/20/09. Technical violation issued. LPA discovered that the facility has not been conducting disaster drills. Deficiency issued.

Deficiencies, one technical violation and one civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC421IM and appeal rights were discussed and copies were provided to the administrator, Maria Lucas.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 04/11/2024 12:13 PM - It Cannot Be Edited

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: MAEMAR MANOR	FACILITY NUMBER: 366413049
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in having a bedridden resident without approved fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/12/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will issue a 60 day eviction notice to resident's responsible party and will review the regulation cited and submit a statement of understanding to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 04/11/2024 12:13 PM - It Cannot Be Edited

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: MAEMAR MANOR	FACILITY NUMBER: 366413049
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the administrator did not comply with the section cited above in maintaining the facility clean, safe and in good repair which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will fix the broken bedroom closet; make all medication and chemicals inaccessible to residents and clean the residents bedrooms. Administrator stated that she will pictures of the corrections to LPA via email by POC due date.

Type B

Section Cited

CCR

87303(f)(1)

Maintenance and Operation

(f) Solid waste shall be stored and disposed of as follows: (1) Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the administrator did not comply with the section cited above in storing and disposing solid waste which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will hold a training with staff going over the regulation, submit proof of attendance with staff's signature and email a copy to LPA via email by POC due 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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 04/11/2024 12:13 PM - It Cannot Be Edited

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: MAEMAR MANOR	FACILITY NUMBER: 366413049
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in including updated physician's reports and personal rights forms for each resident which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will submit updated physician's reports and personal rights forms for all residents to LPA via email by POC due date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in conducting disaster drills which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will train staff on regulation cited, conduct quarterly disaster drills and maintain a log available for inspection. Administrator stated that she will submit a statement of understanding on regulation cited and submit a copy to LPA via email by POC due 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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6