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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881001
Report Date: 10/08/2024
Date Signed: 10/08/2024 12:17:22 PM

Document Has Been Signed on 10/08/2024 12:17 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:BARDWELLS PINES MANOR LLCFACILITY NUMBER:
331881001
ADMINISTRATOR/
DIRECTOR:		HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:5336 BARDWELLS AVETELEPHONE:
(786) 219-6008
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 6DATE:
10/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Najeh HamedTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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Licensing Program Analyst (LPAs), Armando Perez and Ferrer Sabarias made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPAs were granted entry by staff to conduct the inspection and met with administrator,Najeh Hamed. The LPA informed the Administrator of the purpose for the visit. The inspection included the following:

The facility consists of five (5) bedrooms, three (3) bathrooms, a kitchen and dinning area, a living room area, a garage and laundry room, and a patio and yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator, 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.

LPAs began review of client records. Five (5) records were reviewed. LPAs 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.

LPAs began review of employee records- Three (3) records were reviewed. LPAs 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 10/01/2024.Administrator provided proof of payment and the pending status email. Payment was made on 07/26/24.

LPAs 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.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BARDWELLS PINES MANOR LLC
FACILITY NUMBER: 331881001
VISIT DATE: 10/08/2024
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Medications are centrally stored. There is a locked kitchen cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

LPAs 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 and found to be operational. Fire extinguishers was recharged this year, 08/01/2024. The facility is conducting emergency disaster/fire drills quarterly; last done on 09/21/2024.

Based on the information received during this visit today in the areas reviewed, there are no deficiency that are being cited per Title 22, Division 6 of The California Code of Regulations. 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: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
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