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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880633
Report Date: 03/11/2025
Date Signed: 03/11/2025 12:28:24 PM

Document Has Been Signed on 03/11/2025 12:28 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CALIFORNIA MANOR GUEST HOME #1FACILITY NUMBER:
331880633
ADMINISTRATOR/
DIRECTOR:		HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:8536 & 8548 CALIFORNIA AVETELEPHONE:
(786) 219-6008
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 12CENSUS: 10DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Caregiver Fermin CarnistaTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with caregiver, Fermin Carnista. LPA was informed that Fermin is authorized to assist and provide the required documents for todays visit. The inspection included the following:

The facility consists of two buildings. Building 8536 and Building 8548. Both building have a layout consisting of four (4) resident bedrooms, one (1) staff room, two (2) bathrooms, a kitchen and dinning area, a living room area, a garage and laundry room, a covered patio and yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to staff, no weapons are stored in the home. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. LPA observed the flooring to be sticky in the hallway and living room of building 8536. A technical assistance will be documented.

LPA began review of client records. seven (7) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be incomplete, a deficiency was cited.

LPA began review of personnel records- three (3) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 10/01/2026. LPA observed personnel records to be incomplete and a deficiency was cited.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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Document Has Been Signed on 03/11/2025 12:28 PM - It Cannot Be Edited


Created By: Armando Perez On 03/11/2025 at 11:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CALIFORNIA MANOR GUEST HOME #1
FACILITY NUMBER: 331880633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 two counts which poses an immediate health, safety or personal rights risk to persons in care. Two knives were found to be stored in an unsecured, unlocked cabinet in the kitchen and cleaning chemicals were found under the bathroom sink.
POC Due Date: 03/21/2025
Plan of Correction
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Staff immediately relocated two knives and chemicals to a secured, locked cabinet. Administrator will need to provide a refresher training with staff on securing and storing of sharps and chemicals and email proof to LPA. The immediate correction was made and Administrator has 10 days to submit the proof of correction to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jazmond D Harris
LICENSING EVALUATOR NAME:Armando Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 03/11/2025 12:28 PM - It Cannot Be Edited


Created By: Armando Perez On 03/11/2025 at 11:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CALIFORNIA MANOR GUEST HOME #1
FACILITY NUMBER: 331880633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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 two out of two counts which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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A carbon Monoxide unit will need to be installed in building 8536 and a battery or replacement is needed for Carbon monoxide unit in building 8548. Administrator will submit photo proof of the new unit and a copy of the receipt.
Type B
Section Cited
CCR
87307(e)
Personal Accommodations and Services
(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in four out of seven persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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LPA observed Physicians reports needing to be updated for four out of seven residents reviewed. A Reappraisal was not available to provide an assessment of their current condition. An updated Physicians report will need to be submitted for the required residents. A list was left with staff.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Armando Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/11/2025 12:28 PM - It Cannot Be Edited


Created By: Armando Perez On 03/11/2025 at 11:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CALIFORNIA MANOR GUEST HOME #1
FACILITY NUMBER: 331880633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one out of one person which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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LPA could only review the Administrators Certificate for Administrator Najeh Hamed. Administrator needs to have a personnel file available for review. Administrator will email a complete file to LPA to clear deficiency.
Type B
Section Cited
CCR
87412(e)
Personnel Records
(e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one out of one schedule which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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LPA observed an LIC 500 with just names and could not determine the hours and days worked for each staff that is associated. According to staff, they are here most of the week and its unclear if sufficient staff is present at all times during the week. Admiistrator will email a complete and updated LIC 500 wih the days and times of each staff. The information must provide coverage for each shift all week.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Armando Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 03/11/2025 12:28 PM - It Cannot Be Edited


Created By: Armando Perez On 03/11/2025 at 11:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CALIFORNIA MANOR GUEST HOME #1
FACILITY NUMBER: 331880633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in seven out of seven persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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LPA observed the MAR record to be missing for the month of March. According to staff, the Administrator has not provided the new month to document the distribution of medication. Administrator will email the Mar logs for March for the seven residents.
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in four out of seven persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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Administrator will email completed physicians reports for the four residents that are in need of an updated physicians report.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Armando Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CALIFORNIA MANOR GUEST HOME #1
FACILITY NUMBER: 331880633
VISIT DATE: 03/11/2025
NARRATIVE
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LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen. LPA observed two knives stored in an unlocked cabinet in the kitchen and chemicals stored under a bathroom sink. Staff immediately secured items to the correct location, a deficiency was cited.

Medications are centrally stored. There is a locked closet allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications records reviewed was incomplete, a deficiency was cited.



LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested. Carbon Monoxide detector was missing in one building and inoperable in the other building. A deficiency was cited. Fire extinguishers was serviced on 10/25/2024. Fire drills are conducted quarterly at the facility with the last drill on 01/16/2025 .

Based on the information received during this visit today in the areas reviewed, there are deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations. Corrections will need to be submitted to be cleared

This LIC 809 report was reviewed with the facility representative and a copy was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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