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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413258
Report Date: 12/15/2021
Date Signed: 12/15/2021 12:27:40 PM

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
RIVERSIDE, CA 92507
FACILITY NAME:MISSION COMMONSFACILITY NUMBER:
366413258
ADMINISTRATOR:SORIANO, MARIANFACILITY TYPE:
740
ADDRESS:10 TERRACINA BLVDTELEPHONE:
(909) 307-6251
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:59CENSUS: 33DATE:
12/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Karla JerezTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a case management visit related to a power outage at the facility 12/14/2021. The facility current houses 33 residents. Two residents (R1 & R2) at the facility have a Dementia diagnosis. Those residents had one on one supervision during time of power outage. The facility had a portable power generator on site and an additional generator was rented for additional power if needed. Power was lost at the facility on 12/14/2021 at approximately 11 AM. Communication with the power company (Edison) stated that power would be restored at approximately 1:30 PM then soon after Edison stated power would be restored at approximately 11 PM. Power was eventually restored at approximately 6:30 PM on 12/14/2021.

During on site visit, LPA Prieto interviewed Executive Director Karla Jerez and review the facility Disaster Manual, which included, but not limited to Plan for Epidemic Outbreaks (Mitigation Plan), Maintenance Vendor Emergency Numbers, Emergency Action Plan, Disaster procedures, Chain of Command, Safety monitors, Disaster and Emergency Core Teams, Evacuating the Building, Shutoffs and Controls. Also Disaster checklist: Utilities Outages, Elevator Failure, Contaminant Release. The facility also has a 72 hour Self-Reliance Plan, which was put in place during outage. Emergency Lighting, which the facility incorporated with battery powered flash lights and lanterns. Emergency Supplies, Dining Services Disaster Readiness Plan, and disaster drills.

Facility is currently operating business as normal. There was no soilage of facility food or resident medication during the outage. Facility fees are current. A copy of this report was signed by Executive Director Jerez and LPA Prieto and a copy was left with the facility.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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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