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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604325
Report Date: 09/19/2023
Date Signed: 09/19/2023 11:17:05 AM


Document Has Been Signed on 09/19/2023 11:17 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:MARAMAFACILITY NUMBER:
374604325
ADMINISTRATOR:SANDISON, HEATHERFACILITY TYPE:
740
ADDRESS:727 ASCOT DRIVETELEPHONE:
(760) 505-3019
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY:12CENSUS: 6DATE:
09/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Facility Manager Lexi KopackTIME COMPLETED:
11:17 AM
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Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 9:38 a.m. to conduct an unannounced annual visit. LPA met with Facility Manager Lexi Kopack at the front door and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for 12 non-ambulatory residents, 2 bedridden residents. The facility has 6 residents in care.
Infection Control Plan:
The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies.
Physical Plant and Environmental Safety: The facility is a three-story home. The facility temperature read at 72 degrees. The facility consists of 10 resident bedrooms, and 8 bathrooms, living room, kitchen, patio, gym, and backyard. The bedrooms are furnished with lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 116 degrees within regulation requirements. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked medication cart and inaccessible to residents. The upstairs portion of the home contains staff breakroom, the second floor consists of resident bedrooms and a kitchen, which is being remodeled, and third floor consists of resident bedrooms and kitchen. The facility has a current fire clearance for the facility, smoke and carbon monoxide detectors and fire extinguishers and are in working order.
Personnel Records-Training: The staff records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings.
Client Records-Incident Reports: The facility has identification and emergency information, physician’s report, resident appraisal, client rights, and admissions agreement contained in online program called August Health.

(Continued on LIC809-C)
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl GoodrichTELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MARAMA
FACILITY NUMBER: 374604325
VISIT DATE: 09/19/2023
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(Continued from LIC809)

Client Rights-Information: The facility has client rights information posted in the facility.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available.
Health- Related Services: The facility has an electronic medication logbook and a physical copy, and the facility documented the resident’s medication and in compliance with physician’s orders and regulations.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 09/29/23. The facility has emergency supply of food and water.
Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with Facility Manager Lexi Kopack and a copy of this report was printed Signature below confirms receipt of these rights.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl GoodrichTELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC809 (FAS) - (06/04)
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