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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425333
Report Date: 01/04/2024
Date Signed: 01/04/2024 11:23:14 AM

Document Has Been Signed on 01/04/2024 11:23 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: 2DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Michael Sangkay, Care ProviderTIME COMPLETED:
11:30 AM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Ami-Mariana House, Adult Residential Facility unannounced to conduct the Annual Inspection. LPA introduced self and stated purpose of the visit. LPA was greeted and granted entry by Care Providers, Michael Sangkay and Marli Sangkay. LPA was informed the Administrator, Vergel Santos was notified of LPA visit and arrived later during visit.

Facility: The facility is licensed and approved for five, (5) residents, one, (1) non-ambulatory and four, (4) ambulatory adults. The facility is operating at the capacity and in the conditions approved by Community Care Licensing (CCL). Also, the facility maintains a partnership with the Inland Regional Center, (IRC)



Physical Plant: LPA Coleman observed the facility to be within a comfortable temperature. Sufficient lighting is provided throughout the residence; by various light fixtures and night-lights. LPA observed numerous fire/smoke and carbon monoxide alarms throughout the facility. Devices were tested and found operational. Fire Extinguishers were fully charged and last inspected March 2023. Care providers report the facility holds monthly fire/disaster drills. LPA observed no pool or bodies of water on facility grounds. Interior and Exterior pathways were free of clutter and obstructions. Facility bathrooms included bathing areas with non-slip materials, handrails, operational appliances and adequate hand hygiene supplies. Each resident room contained a bed with adequate linens, ample storage space, sufficient lighting, seating and privacy for each resident. The living room spaces contained adequate seating for residents, guests and visitors.

Food Service: The food supplies are located in 3 refrigerators/freezers in the kitchen and garage. LPA observed sufficient amounts of both perishable and non-perishable for the amount of residents in care. Facility offers a variety of food items available for residents, LPA observed eggs, breads, milk, condiments, frozen meal and fresh fruits and vegetables throughout food storage. LPA also observed properly stored utensils and dishware; in good condition. Care provider, Marli showed LPA that the sharp objects are kept in
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 01/04/2024
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a secure drawer. Also, chemicals and cleaning supplies are kept secure under the kitchen sink. All inaccessible to residents.
Care & Supervision: Facility has sufficient care staff; who assist residents 24 hours and 7 days a week. There are currently 2 staff members who resident on facility property. A review of staff records revealed all staff have all documentation and verification of training as required by regulation.

Record Review and Resident/Staff Files: LPA Coleman reviewed resident records for four, (4) residents currently living at the facility. Resident records contained physician reports and Needs and Services Plans. Out of 4 resident files, 4 residents did not have /current updated Physician’s Reports. The Administrator's Administrator Certificate was observed in compliance.
Administration: Disaster Plan, Ombudsman poster, If you see something, say something poster, Personal Rights and emergency disaster plan/facility map are posted throughout the facility. Emergency Disaster Plan is current.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and secure in a file cabinet in nurse station. LPA reviewed 4 of the residents' medication lists. Centrally Stored Medication Log. LPA Coleman did not observe any medication errors at the time.

Based on observation, interviews and record reviews, a deficiency is being cited to address concerns listed above. Exit interview conducted and copy of this report was reviewed, discussed then provided to Administrator/Licensee Vergel Santos.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
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Document Has Been Signed on 01/04/2024 11:23 AM - It Cannot Be Edited


Created By: Amber Coleman On 01/04/2024 at 11:08 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AMI-MARIANA HOUSE
FACILITY NUMBER: 366425333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)(1)
80069 - Client Medical Assessment
In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.
(1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and review of records, the licensee did not comply with the section cited above by not ensuring that each resident in care had a current/updated Physician's Report (LIC602) on file; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Administrator/Licensee agrees to work with resident family members and residents Primary Care Physicians to get their Physician's Reports completed/updated. Administrator agrees to submit verification of completion of the task to the Community Care Licensing Office within 30 business days.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024


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