366426418-7-27-2023-56-AS-MECA-CU5SWF-20230727141415

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426418
Report Date: 07/27/2023
Date Signed: 07/27/2023 02:14:28 PM

Document Has Been Signed on 07/27/2023 02:14 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	M&M BOARD & CARE		FACILITY NUMBER:	366426418
ADMINISTRATOR:	MERCADO, VICTOR		FACILITY TYPE:	740
ADDRESS:	18245 CHERRY ST.		TELEPHONE:	(760) 488-1698
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY:	8	CENSUS: 3	DATE:	07/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Victor Mercado-Administrator		TIME COMPLETED:	02:20 PM

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	On 07/27/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Victor Mercado and introduced self and stated the purpose of the visit. LPA was informed that there are currently 3 residents in care who will be leaving shortly to senior program. The facility has 4 resident bedrooms, 2 resident bathrooms, 2 staff bedrooms, 1 staff bathroom, living room, kitchen, dining area, laundry room, backyard and 2 storage sheds. LPA completed a walk through of the facility and review of records. Physical Plant: The facility is maintained at a comfortable temperature of 78 degrees farenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. LPA observed a trash can in resident's bathroom without a tight-fitting cover. Deficiency issued. Water temperature tested at 116.9 degrees farenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and 3 fire extinguishers. Posters such as; the personal rights, CCL complaint poster and ombudsman were posted in a common area. LPA observed the emergency and disaster plan missing. Deficiency issued. LPA also observed an old facility license with the incorrect capacity number posted. Technical violation issued. LPA observed chemicals left unlocked underneath kitchen sink, knives and medication unlocked inside kitchen drawers. Deficiency issued. There was a designated storage space for residents/staff files. First aid kit was observed in a locked closet inaccessible to residents. There are no pools, bodies of water, firearms or ammunition. There are no obstructions to indoor and outdoor passageways. The facility is not clean, in good repair, and operating in safe conditions for residents in care. LPA observed counters with food crumbs, refrigerator with moldy liquid and stains inside, greasy stove with fan, dirty floors, and dead flies by windows. Deficiency issued.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 8

Document Has Been Signed on 07/27/2023 02:14 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: M&M BOARD & CARE	FACILITY NUMBER: 366426418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the Administrator did not comply with the section cited above in storing chemicals, knives and medication locked and secured from residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Administrator immediately locked chemicals, knives and medication. Administrator stated that he will review regulation 87309(a) and submit proof of training to LPA via email by 08/10/23.

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the Administrator did not comply with the section cited above in obtaining criminal record clearance for mother and aunt which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Administrator stated that he will not allow mother and aunt to sleep over until obtaining criminal record clearance. Administrator will provide LPA with proof of clearance and updated roster via email by 08/10/23.

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: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 8

Document Has Been Signed on 07/27/2023 02:14 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: M&M BOARD & CARE	FACILITY NUMBER: 366426418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the Administrator did not comply with the section cited above in maintaining 2 days of perishable food supply which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Administrator stated that he will go grocery shopping and replenish the 2 day supply of perishable food. Administrator stated that he will submit photos of food and receipt to LPA vial email by POC due date.

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: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

Page: 3 of 8

Document Has Been Signed on 07/27/2023 02:14 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: M&M BOARD & CARE	FACILITY NUMBER: 366426418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(f)(3)

Maintenance and Operation

(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the Administrator did not comply with the section cited above in having a trash can with a tight-fitting cover inside resident's bathroom which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2023
	Plan of Correction
1 2 3 4	Administrator stated that he will purchase a trash can with a tight-fitting cover for the resident's bathroom. Administrator stated that he will submit proof of picture and receipt to LPA by POC due date via email.

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the Administrator did not comply with the section cited above in ensuring himself with a non-expired CPR and first aid training certification which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2023
	Plan of Correction
1 2 3 4	Administrator stated that he will renew his CPR and first aid certification and submit proof to LPA via email by POC due date.

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: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

Page: 4 of 8

Document Has Been Signed on 07/27/2023 02:14 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: M&M BOARD & CARE	FACILITY NUMBER: 366426418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(4)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the Administrator did not comply with the section cited above in maintaining a clean, safe, sanitary and in good repair facility at all times which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2023
	Plan of Correction
1 2 3 4	Administrator stated that he will deep clean counters, refrigerator, stove with fan, floors, and windows; and submit pictures as proof to LPA via email by POC due date.

Type B

Section Cited

CCR

87412(a)(13)(B)1

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the Administrator did not comply with the section cited above in ensuring himself with a current and valid Administrative Certification which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2023
	Plan of Correction
1 2 3 4	Administrator stated that he will enroll and complete the Administrative Certification. Administrator stated that he will submit proof to LPA via email by POC due date.

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: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

Page: 5 of 8

Document Has Been Signed on 07/27/2023 02:14 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: M&M BOARD & CARE	FACILITY NUMBER: 366426418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the Administrator did not comply with the section cited above in maintaining complete records for all residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2023
	Plan of Correction
1 2 3 4	Administrator stated that he will create and complete missing documentation for each resident's record. Administrator stated that he will submit proof to LPA via email by POC due date.

Type B

Section Cited

HSC

1569.695(a)

Other Provisions

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the Administrator did not comply with the section cited above in having an emergency and disaster plan posted which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2023
	Plan of Correction
1 2 3 4	Administrator stated that he will create, complete and post an emergency and disaster plan. Administrator stated that he will submit proof via email to LPA by POC due date.

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: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

Page: 6 of 8

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: M&M BOARD & CARE	FACILITY NUMBER: 366426418
	VISIT DATE: 07/27/2023

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
26
27
28
29
30
31
32

Food Service: There is a 7 day supply of non-perishable food. LPA observed that there is not a 2 day supply of perishable food for number of residents in care. Deficiency issued. Dishes, cups, and utensils were stored properly.

Yards/Outside: One shaded patio, two sheds, and a side gate with self-latching handle on the right side of the house that leads into the backyard.

Record Review: LPA reviewed residents files for admission agreements, updated physician reports, and needs and services plans. LPA observed a missing and incomplete record for 2 residents. Deficiency issued. LPA reviewed the Administrator's record for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that the Administrator's CPR and First Aid certification expired on April of 2017. Deficiency issued. LPA also observed the Administrator's certificate expired on 04/10/2017. Deficiency issued. Per interview, observation and record review, Administrator stated that his mother and aunt sleep over during some weekends. Mother and aunt do not have criminal record clearance. Deficiency with civil penalty issued.

One technical violation, deficiencies and civil penalties were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC421BG and appeal rights were discussed and copies were provided to the Administrator, Victor Mercado.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

Page: 8 of 8