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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530136
Report Date: 04/02/2024
Date Signed: 04/02/2024 05:07:19 PM

Document Has Been Signed on 04/02/2024 05:07 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ASSISTED LVG & MEMORY CARE HOME AT WILDROSE RANCHFACILITY NUMBER:
335530136
ADMINISTRATOR:GARCIA, DOMINICFACILITY TYPE:
740
ADDRESS:22877 MOUNTAIN ASH CIRCLETELEPHONE:
(951) 310-4622
CITY:CORONASTATE: CAZIP CODE:
92883
CAPACITY: 6CENSUS: 0DATE:
04/02/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Romulo Garcia/AdministratorTIME COMPLETED:
05:11 PM
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Licensing Program Analyst (LPA) Bianca Wolcott conducted an announced visit to the pending facility for the purpose of conducting the pre-licensing inspection. LPA met with applicant Romulo Garcia/ Administrator.

LPA Wolcott, toured the facility inside and out. The pending application is for six (6) non-ambulatory residents in a Residential Care Facilities for the Elderly, where one (1) can be bedridden in room #3. Granted for Hospice Care for six (6) residents. No residents are currently living at facility. The following was observed, reviewed, and inspected: there are three (3) resident bedrooms and two (2) resident bathrooms. There are no bodies of water. The physical plant, in general, was in good repair. Buildings and grounds were free of hazards. Outdoor and indoor passageways were kept free of obstruction. There are charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. There is a locked area for cleaning supplies, medications, and sharps. Cleaning supplies were stored underneath the kitchen sink in a locked cabinet. Laundry room soap will be stored in the locked garage with additional chemicals. Medications will be stored in a locked kitchen cabinet. Sharps were stored in a locked drawer. LPA toured the resident bedrooms. Resident bedrooms had the required furniture, chair, bedding, and functional lighting. The facility had a supply of additional linen and extra hygiene items for the residents. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a menu available for review. The facility had a two (2) day supply of nonperishable food items and seven (7) day supply of nonperishable food items. Dishes, glasses, and utensils were in good condition. The facility had a designated area for staff and resident files in a locked cabinet. LPA toured the resident bathrooms. The bathrooms were operating in safe and sanitary conditions. LPA observed grab bars in the shower area. LPA measured the hot water temperature in the bathrooms. The hot water temperature measured 113 degrees F. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. The facility was equipped with a complete first aid kit (e.g. thermometer, tweezers, scissors, antiseptic, bandages, gauze). There is adequate seating in the common areas. Facility had activity calendar for the residents for review. Emergency lighting (e.g. flashlights) were also maintained. Component III slideshow was conducted with Romulo Garcia/ Administrator, and copy of report was provided.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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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