335530063-2-13-2023-56-AS-ACON-CNZUDE-20230213142925

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530063
Report Date: 02/13/2023
Date Signed: 02/13/2023 02:29:58 PM

Document Has Been Signed on 02/13/2023 02:29 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:	SIERRA PINES GUEST HOME		FACILITY NUMBER:	335530063
ADMINISTRATOR:	HAMED, HANAN		FACILITY TYPE:	740
ADDRESS:	5051 LA SIERRA AVE		TELEPHONE:	(786) 219-6008
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92505
CAPACITY: 25		CENSUS: 6	DATE:	02/13/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Hanan Hamed, Administrator		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst, Amber Coleman (LPA) arrived to the Sierra Pines Guest Home to conducted an announced Pre-Licensing Visit. LPA was greeted and invited inside the facility by Najeh Hamed, Licensee. LPA introduced self and stated purpose of the visit. LPA was asked to sign in and provided a space to work inside the Administrator Office. LPA observed a COVID station upon entry which included hand hygiene, extra masks and paper supplies. LPA and Licensee were accompanied by Administrator, Hanan Hamed. Pending application is for a change in ownership. Former Administrator Laura Nazareno. Administrator reported that there are 6 residents present during visit. There are currently 24 residents in care. LPA, Administrator and Licensee completed a walk through of facility's outside, kitchen, resident rooms, living rooms and dining area. There are a total of 14 rooms. 2 staff rooms and 12 resident rooms. Each resident room contained adequate furniture, supplies and space for each resident. 6 Bathrooms. 2 bathrooms for staff and 4 bathrooms for residents. Each bathroom was orderly and contained adequate amounts of hand soap and paper supplies. Smoke and Carbon Monoxide alarms located in each room and hallway tested and found operational. 2 staff rooms are located on second floor along with facility's laundry room. Laundry room contains to washers and 2 dryers. There are no bodies of water. The physical plant, in general, was in good repair. The buildings and grounds were free of hazards. Outdoor passage way observed to be obstructed by over grown vegetation. Indoor passageways were kept free of obstruction. The outside of the facility had a shaded area with adequate seating for residents. The facility's designated area for client files, staff files, and P& I funds is the Administrator office near front entrance.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SIERRA PINES GUEST HOME	FACILITY NUMBER: 335530063
	VISIT DATE: 02/13/2023

NARRATIVE

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Kitchen includes 2 secure entryways. At 12:25pm LPA observed numerous flying insects flying in the kitchen closet. Administrator explained, this was the designated area for chemical solutions and recycled cans. Medications are kept in the kitchen secure on a cart. Medications and Medication records are delivered on a monthly basis by a local pharmacy. LPA observed kitchen refrigerators and pantries to have sufficient amounts of food to support the current census.

LPA observe the emergency disaster plan, exit plan, personal rights, or complaint procedures posted. Emergency phone numbers, Let-Us-No poster, and client’s rights posted throughout prominent areas of facility.

LPA observe night lights throughout hallways in non-private bathrooms area. LPA observe additional paper towels, toilet paper or cleaning supplies in the hallway closets in the main hallway near resident bedrooms. LPA measured hot water temperature at 110 degrees F. LPA reviewed resident and staff records. LPA observed a number of resident files missing required documentation.

LPA observe activity supplies /equipment variety of reading materials such as magazines, newspapers kept in cabinets in the dining room; along with an Activities Calendar. LPA observe an operating facility telephone and menus for residents.

An exit interview was conducted, and a copy of this report LIC 809 and LIC809C was discussed and provided to the Administrator Hanan Hamed.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023

LIC809 (FAS) - (06/04)

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