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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426418
Report Date: 05/25/2022
Date Signed: 06/02/2022 02:53:02 PM


Document Has Been Signed on 06/02/2022 02:53 PM - It Cannot Be Edited

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
, CA 92507



FACILITY NAME:M&M BOARD & CAREFACILITY NUMBER:
366426418
ADMINISTRATOR:MERCADO, VICTORFACILITY TYPE:
740
ADDRESS:18245 CHERRY ST.TELEPHONE:
7604881698
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:8CENSUS: 4DATE:
05/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Victor Mercado, Administrator TIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rayshaun Nickolas conducted an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Nickolas arrived and met with Administrator, Victor Mercado. The administrator confirmed that there are currently no cases/exposures of COVID-19 within the facility.

During the inspection, LPA Nickolas conducted a tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA Nickolas observed appropriate postings throughout the facility, including hand-washing etiquette, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA observed that the facility staff were wearing face coverings. The facility has a designated infection control lead person who has been tasked 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 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.

LPA observed resident lying on feces stained bedspread. LPA observed a dishwasher, mattress, crutches, and wheel chairs stored in the backyard. LPA observed heavily stained kitchen cabinets and counter tops. LPA was unable to locate the emergency disaster plan (LIC 610E) and Mercado confirmed that the facility has not completed the emergency disaster plan (LIC 610E).
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: M&M BOARD & CARE
FACILITY NUMBER: 366426418
VISIT DATE: 05/25/2022
NARRATIVE
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Based on observations made during today’s inspection, three deficiencies was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy of this report was provided to Mercado at the conclusion of the inspection.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 06/02/2022 02:53 PM - 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: M&M BOARD & CARE
FACILITY NUMBER: 366426418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(c)
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPA observed resident lying on a feces stained bedspread .This poses an immediate health and safety risks for persons in care.
POC Due Date: 05/26/2022
Plan of Correction
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Licensee shall remove feces stained bedspread and provide resident with a clean bedspread. Licensee shall submit proof of correction to LPA on May 26, 2022 by the close of business.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 06/02/2022 02:53 PM - 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: M&M BOARD & CARE
FACILITY NUMBER: 366426418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in storing a dishwasher, mattress, crutches, wheelchairs in the backyard. This poses a potential health and safety risk to persons in care.
POC Due Date: 06/27/2022
Plan of Correction
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Licensee shall remove dishwasher, mattress, crutches, wheelchairs stored in the backyard. Licensee shall submitt proof of removal to the LPA by June 27, 2022 by the close of business.
Type B
Section Cited
CCR
87212(a)-(c)
87212 Emergency Disaster Plan (a)-(c)

(a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.
(b) The plan shall be subject to review by the Department and shall include...



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above in not completing and posting Emergency Disaster Plan (LIC 610E). Which poses a potential health and safety risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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Licensee shall complete and post Emergency Disaster Plan (LIC 610E). Licensee shall submit copy of the facility's Emergency Disaster Plan (LIC 610E) to LPA on May 31, 2022 by the close of business.

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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 06/02/2022 02:53 PM - 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: M&M BOARD & CARE
FACILITY NUMBER: 366426418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above, facility's kitchen cabinets and counters are heavily stained.Which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/26/2022
Plan of Correction
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Licensee shall clean and santize kitchen cabinets and counters. Licensee shall submit proof of correction to LPA on May 26, 2022 by the close of business.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5