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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606472
Report Date: 01/19/2024
Date Signed: 01/19/2024 04:13:04 PM

Document Has Been Signed on 01/19/2024 04:13 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BANNER RIDGE COUNTRY HOMEFACILITY NUMBER:
197606472
ADMINISTRATOR:ELNA C. VILLAFLORFACILITY TYPE:
740
ADDRESS:1006 BANNER RIDGE ROADTELEPHONE:
(909) 240-1899
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 4DATE:
01/19/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Raquel Salen, StaffTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the annual inspection. LPA arrived unannounced and met with staff, Raquel Salen. Administrator, Elna Villaflor arrived shortly after. The initial inspection was conducted on 1/12/24.

LPA conducted the remainder of the domains using the CARE tool and observed the following:
Staffing: There is sufficient staffing at the facility. Staff employed have fingerprint clearance and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training that meet the annual requirement. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, and Resident rights. Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability. Incidental Medical & Dental: Medications are centrally stored and in their original bubble packs. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed all 4 residents' medications and they are being administered as prescribed by the physician. Disaster Preparedness: The facility has an Emergency Disaster Plan easily accessible with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. Staff training include proper care and supervision for residents with dementia.

No deficiencies were issued today. However, technical advisories were provided. An exit interview was held. A copy of this report and technical advisory notes were given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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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