366426418-7-20-2024-56-AS-MMAE-D7CQDL-20240720120456

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426418
Report Date: 07/20/2024
Date Signed: 07/20/2024 12:05:48 PM

Document Has Been Signed on 07/20/2024 12:05 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: 4	DATE:	07/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Victor Mercado - Administrator		TIME COMPLETED:	12:08 PM

NARRATIVE

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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Victor Mercado, Administrator, and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (8), and a current census of (4). LPA conducted an inspection of facility, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. The facility was maintained at a comfortable temperature. Resident bedrooms were furnished with beds, night stands, chairs, storage space, and sufficient lighting. Resident bathrooms were inspected. Hand washing basins, toilets, and showers were operating properly. The hot water temperatures in the bathrooms measured at 117 degrees F. The shower floor in the bathroom across from room#1 was not maintained cleaned and sanitary. The bathroom located in the back of the facility, did not have a non-skid mat or non-skid strips in the shower. The facility maintains a sufficient supply of personal hygiene products for residents in care. The facility is equipped with operating smoke/carbon monoxide alarms and telephone service. The facility has posted in a common area: resident personal rights, Community Care Licensing complaint poster, Ombudsman poster, theft and loss policy, and house rules.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Kitchen counters and kitchen sink were cluttered with dirty dishes.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024

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: M&M BOARD & CARE	FACILITY NUMBER: 366426418
	VISIT DATE: 07/20/2024

NARRATIVE

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Medications/Record Review: LPA did not review medications, staff and resident files. LPA asked Administrator Mercado for staff and resident records and Administrator stated to give him a minute. LPA waited 15 minutes and asked Administrator again, Administrator stated to give him another minute as he had a headache. After an additional 25 minutes, Administrator was holding an apple and stated to LPA he was going to eat something then would assist LPA.

Based on LPA observations and records reviewed, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where reports (LIC809 & LIC809-D) were discussed and copies were provided with appeal rights to Administrator Mercado at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/20/2024 12:05 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: 07/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by not maintaining non-skid mats or strips in resident bathroom located in the back of the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit proof of non-slip mat or strips in resident bathroom by due date.

Section Cited

Other Provisions


	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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024

LIC809 (FAS) - (06/04)

Page: 3 of 8

Document Has Been Signed on 07/20/2024 12:05 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: 07/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(a)

Personnel Requirements - General

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by not having access to staff schedule; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall provide a copy of current staff schedule to Licensing Agency 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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024

LIC809 (FAS) - (06/04)

Page: 4 of 8

Document Has Been Signed on 07/20/2024 12:05 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: 07/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(f)

Personnel Records

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by not having access to personnel records readily avaible upon LPA request; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit a statement of understanding of the regulation cited by POC due date.

Section Cited

Personnel Records


	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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024

LIC809 (FAS) - (06/04)

Page: 5 of 8

Document Has Been Signed on 07/20/2024 12:05 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: 07/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(c)

Personnel Records

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by LPA was not provided records of trainings; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit a statement of understanding of the regulation cited by POC due date.

Section Cited

Personnel Requirements - General


	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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024

LIC809 (FAS) - (06/04)

Page: 6 of 8

Document Has Been Signed on 07/20/2024 12:05 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: 07/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by kitchen counters and sink was cluttered with dirty dishes; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit proof of kitchen is cleaned and uncluttered by POC due date.

Section Cited

Incidental Medical and Dental Care Services


	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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024

LIC809 (FAS) - (06/04)

Page: 7 of 8

Document Has Been Signed on 07/20/2024 12:05 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: 07/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87506(a)

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by not providing resident records upon LPA request; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit a statement of understanding of the regulation cited 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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024

LIC809 (FAS) - (06/04)

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