366423954-2-15-2024-56-AS-ACON-D2GQ6K-20240215105340

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366423954
Report Date: 02/15/2024
Date Signed: 02/15/2024 10:55:01 AM

Document Has Been Signed on 02/15/2024 10:55 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:	WASHINGTON FAMILY MANOR		FACILITY NUMBER:	366423954
ADMINISTRATOR:	WASHINGTON, SIMONE		FACILITY TYPE:	740
ADDRESS:	2235N. ARROWHEAD AVE		TELEPHONE:	(909) 562-4101
CITY:	RIALTO	STATE: CA	ZIP CODE:	92377
CAPACITY:	6	CENSUS: 2	DATE:	02/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Simone Washington, Administrator		TIME COMPLETED:	10:50 AM

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, Amber Coleman, (LPA) arrived at Washington Family Manor unannounced to conduct the facility's Annual Inspection. LPA rang the doorbell and was greeted by Simone Washington, Administrator. LPA introduced self and stated purpose of the visit. LPA was granted entry and provided space to work. LPA was then accompanied by Administrator on a tour of the facility grounds. Facility: LPA was informed that the current census is 2. The facility is licensed 6 non-ambulatory residents. Dementia Care Plan in place. Hospice Waiver approval of 2 residents. LPA observed that the facility is operating at the capacity and in the conditions approved by Community Care Licensing (CCL). Physical Plant: LPA Coleman observed the facility's temperatures to be comfortable. Sufficient lighting was provided by various lamps, fixtures and night-lights throughout the facility. LPA observed carbon monoxide and fire alarms throughout facility. Administrator reports the facility conducts fire and disaster drills on a monthly basis. Fire extinguishers were observed to be fully charged; last inspection date March 2023. The facility backyard contained a shaded space and adequate seating. Pathways contained some obstruction. Administrator agreed to remove during the visit. The facility maintains its laundry room, extra hygiene and Personal Protective Equipment and extra supplies secure in the attached garage. The Living Room and Dining Room included activities, adequate seating and sufficient lighting. Resident Rooms included all required furnishings such as beds with appropriate linens, night stand, adequate lighting and seating. The facility does maintain a room for staff where staff files, resident files and medications secure. Food Service: LPA observed the facility's food supply included a variety of items such as eggs, bread, milk, salad, fresh fruits and vegetables. Kitchen pantry with canned goods all in good standing. The amount of Nonperishable and perishable food is sufficient for number of residents in care. LPA observed that sharps, chemicals, cleaning supplies were kept in secure and inaccessible to residents in care. Please see LIC809-C

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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: WASHINGTON FAMILY MANOR	FACILITY NUMBER: 366423954
	VISIT DATE: 02/15/2024

NARRATIVE

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Care & Supervision: Facility has sufficient care staff; who assist residents 24 hours and 7 days a week. Administrator reported that 1 staff member lives on facility grounds and there are 2 other staff who assist part time. A review of staff files revealed that all staff files contained verification of their annual training, criminal record clearance, health screenings, 1st Aid/CPR. The Administrator's Administrator Certificate was observed in compliance.
Resident Records: LPA reviewed resident files for updated Physician's Report's, Needs and Services and Admissions Agreements. LPA observed 1 resident file without a current Physician's Report.

Signs / Posters: Emergency Disaster Plan, Long Term Care Ombudsman, Administrator Certificate, Personal Rights and Facility Sketch, Facility License, SEE/SAY are posted in a prominent place.

Based on observations, staff interviews and record reviews, 1 deficiency will be cited to address records. Exit interview conducted and copy of this report was provided to Administrator/Licensee Simone Washington.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/15/2024 10:55 AM - 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: WASHINGTON FAMILY MANOR	FACILITY NUMBER: 366423954
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87456(a)(3)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviews the licensee did not comply with the section cited above inby not ensuring the Resident's Phsyician's Report was updated/current which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2024
	Plan of Correction
1 2 3 4	Adminstrator agrees to assis the resident with obatining an updated physician's report from the resident's hospice agency. Also submit verification of this completion of this form to the community care licensing office within the next 30 business days.

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: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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