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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530125
Report Date: 06/10/2024
Date Signed: 06/10/2024 11:40:45 AM

Document Has Been Signed on 06/10/2024 11:40 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:OHANA EXCELLENCE ASSISTED LIVINGFACILITY NUMBER:
335530125
ADMINISTRATOR/
DIRECTOR:		MARC, OANAFACILITY TYPE:
740
ADDRESS:18580 MANITOU STREETTELEPHONE:
(951) 268-6060
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 6CENSUS: 4DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Oana Marc - AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Oana Marc, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a current census of (4). LPA conducted a general inspection of facility, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pool or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. The facility is maintained at a comfortable temperature. Resident bedrooms were furnished with mattresses, night stands, chairs, storage space, and sufficient lighting. Resident bathrooms were maintained clean and fixtures were operating properly. The hot water temperatures in the bathrooms measured at 105- and 116- degrees F. The facility maintains a sufficient supply of bed linen, towels, and personal hygiene products for residents in care. The facility is equipped with operating door signals, laundry equipment, telephone service, and carbon monoxide alarm. Posters such as personal rights, CCLD complaint poster, Ombudsman poster, facility license, "Oxygen in Use" signs, facility sketch with exit points, and the disaster plan were posted in appropriate areas of the facility. Medications are label and centrally stored in a locked cabinet. The facility has a first aid kit with manual.

Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply is sufficient for number of residents in care. The facility refrigerator and freezer were operating properly. Cleaning supplies and sharps were kept locked and stored away from food supply.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: OHANA EXCELLENCE ASSISTED LIVING
FACILITY NUMBER: 335530125
VISIT DATE: 06/10/2024
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Care & Supervision: The facility has care staff coverage, 24 hours a day, 7 days a week.

Record Review: Resident files were reviewed for admission agreements, appraisals, physician reports, and services plans. Staff files were reviewed for First Aid/CPR certifications, criminal record clearances, training, and health screenings. The facility's liability insurance and Administrator's certification are current.

Overall the facility is operating in sanitary conditions, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report and report LIC9102 were discussed and copies provided to Administrator Marc at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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