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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425333
Report Date: 12/17/2024
Date Signed: 12/17/2024 11:49:44 AM

Document Has Been Signed on 12/17/2024 11:49 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AMI-MARIANA HOUSEFACILITY NUMBER:
366425333
ADMINISTRATOR/
DIRECTOR:		VERGEL SANTOSFACILITY TYPE:
735
ADDRESS:281 EAST MARIANA ST.TELEPHONE:
(909) 229-7563
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 4CENSUS: 2DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:48 AM
MET WITH:Vergel Santos, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst, LaVette Farlow (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, Jones "Frank" 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 current census is (2) in the facility one (1) is away with family, and the other client is at the day program. 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 Farlow 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 2024. 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 toilet and adequate hand hygiene supplies. LPA tested the water temperature in the kitchen and bathrooms and the temperature were below regulations at 98.6, 99.1, and 102.0. Licensee attempted to adjust the levels, and was unsuccessful. A deficiency was cited. LPA observed the sink would not properly drain the water and the shower was not properly cleaned. A deficiency was cited. 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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AMI-MARIANA HOUSE
FACILITY NUMBER: 366425333
VISIT DATE: 12/17/2024
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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, Michael Sangkay showed LPA that the sharp objects are kept in 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. 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 Farlow reviewed resident records for two, (2) residents currently living at the facility. Resident records contained physician reports and Needs and Services Plans. Out of 2 resident files, 2 residents did not have current IPP reports. A technical advisory was issued. P & I funds were audited and appeared to be managed appropriately. The facility last conducted a disaster drill on November 2024. The Administrator's Administrator Certificate was observed as submitted and waiting for the renewal certificate.
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 for Residential Care Facilities etc LIC610D is not current and was not reviewed annually. The last review was 2021. A technical advisory issued.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and secure in a file cabinet. LPA reviewed 2 of the residents' medication lists and all medication was accounted for and logged. LPA Farlow did not observe any medication errors at the time.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/17/2024 11:49 AM - It Cannot Be Edited


Created By: Lavette Farlow On 12/17/2024 at 11:25 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: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 12/17/2024, observation, the licensee did not comply with the section cited above in 3 out of 3 area with kitchen and bathroom water temperature which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Liceense agreed to have someone come out and service the water heater and adjust the temperature. Licensee agrees to regularly check the temperature and keep a running log of the temperature.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 12/17/2024, observation, the licensee did not comply with the section cited above in 1 out of 1 bathroom and shower for residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Licensee agrees to monitor and maintain an clean shower and bathroom area and to have the sink repair for proper drainage.
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:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


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