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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425333
Report Date: 12/16/2022
Date Signed: 12/27/2022 08:15:46 AM

Document Has Been Signed on 12/27/2022 08:15 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:AMI-MARIANA HOUSEFACILITY NUMBER:
366425333
ADMINISTRATOR:VERGEL SANTOSFACILITY TYPE:
735
ADDRESS:281 EAST MARIANA ST.TELEPHONE:
(909) 229-7563
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 4CENSUS: 3DATE:
12/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Michael Sangkay, CaregiverTIME COMPLETED:
02:00 PM
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Licensing Program Analyst, Amber Coleman (LPA) made an unannounced visit to the Ami-Mariana House Facility to conduct an Annual Inspection with a focus on infection control. LPA introduced self and stated purpose of the visit. LPA was greeted and granted entry by staff member, Michael Sangkay (S1) Staff member introduced himself as a caregiver. LPA was also introduced to staff member 2, Marli Sangkay, Caregiver (S2). LPA signed in and had temperature taken. COVID station was observed near the front entry way of the facility. The station included hand sanitizer, PPE and signs for infection control. LPA was provided a place to work and given a tour of the facility inside and out. The facility was observed to be spacious and free of obstruction.

During inspection, LPA observed signage pertaining to infection control, house rules and licensing regulations. Staff were also observed wearing appropriate PPE throughout the visit. All bathrooms offered hand soap and paper products. Resident's rooms were found orderly and adequately furnished. Fire and Carbon Monoxide Alarms tested during walk through were found operational. Fire Extinguishers were last inspected 3/9/22. S2 reports that the current census is 3 and there are no concerns for the residents at this time. Residents arrived back to the facility during visit. There are 3 staff members on duty who also reside on facility grounds. Medications are kept secure in file cabinets in the facility's living room. Chemicals are kept under the kitchen sink in a secure cabinet. Sharp objects are also kept in the kitchen in a secure drawer. 3 resident charts reviewed. LPA observed resident charts to be complete with sufficient information.

Continued on LIC809C***
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2022
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: AMI-MARIANA HOUSE
FACILITY NUMBER: 366425333
VISIT DATE: 12/16/2022
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The facility has a designated infection control lead person who has been charged with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division (CCLD) guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

Emergency food supply observed to be adequate and kept in a closet near the kitchen as well as the facility garage.

Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, and no deficiencies were noted.



Based on the observations made during today’s visit, there were no deficiencies cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided to facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC809 (FAS) - (06/04)
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