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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336400004
Report Date: 03/12/2025
Date Signed: 03/12/2025 03:14:25 PM

Document Has Been Signed on 03/12/2025 03:14 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:MAYFLOWER GUEST HOME IIFACILITY NUMBER:
336400004
ADMINISTRATOR/
DIRECTOR:		CRISTINA FAJARDOFACILITY TYPE:
740
ADDRESS:11287 NORWOOD AVE.TELEPHONE:
(951) 351-9074
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 15CENSUS: 11DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Administrator Cristina FajardoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 03/12/2025 at M, Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Singh met with Administrator Cristina Fajardo and was granted entry to the facility. At the time of the visit there were fifteen (11) residents and six (6) staff present.

The facility is an eleven (11) bedroom, and four (4) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of fifteen (15) ambulatory residents and the current census is fifteen (11) residents. LPA Singh was accompanied by Administrator Fajardo to conduct a general overall inspection, 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). There are no obstructions to indoor and outdoor passageway. The facility is maintained at a comfortable temperature. LPA Singh inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night-stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Singh measured and observed the water temperature in the bathrooms to be at 108 degrees F and 110 degrees F in second bathroom. The facility is equipped with operating smoke detectors and carbon monoxide alarms. There were five (5) fire extinguishers observed at the facility.

***Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MAYFLOWER GUEST HOME II
FACILITY NUMBER: 336400004
VISIT DATE: 03/12/2025
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Posters such as labor laws, and the disaster plan were posted in a common area, but LPA Singh observed the personal rights, the CCLD complaint poster and Ombudsman poster were posted in a common area.

Cleaning supplies, chemicals and other dangerous items were locked, not accessible to residents. There was a designated storage space for resident/staff files. There is a Medicine cabinet with the resident’s medications locked. LPA Singh observed a complete first aid kit and first aid book at the facility.

Food Service: More than seven (7) days’ supply of non-perishable foods and more than three (3) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has an Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA Singh reviewed three (3) resident files for admission agreements, physician reports, pre-placement appraisals, functional capabilities and needs and services plans. LPA Singh observed there were required pre-placement appraisals, functional capabilities and needs and services plan documentation on file. LPA Singh reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. LPA Singh audited three (3) residents medications were audited and per review of their Medication Administration Record (MAR) was updated.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809C were discussed and provided to Administrator Cristina Fajardo.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
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