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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423397
Report Date: 03/20/2025
Date Signed: 03/20/2025 03:51:30 PM

Document Has Been Signed on 03/20/2025 03:51 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:HAMNER MANORFACILITY NUMBER:
336423397
ADMINISTRATOR/
DIRECTOR:
JAMES VANNOYFACILITY TYPE:
740
ADDRESS:7121 MACKINAW CTTELEPHONE:
(951) 475-5003
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY: 6CENSUS: 5DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:16 PM
MET WITH:Administrator- April Lopez and
House Manager Maria Abaya
TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator April Lopez and was granted entry to the facility. Licensed capacity is (6) current census (5). LPA was accompanied by Administrator April Lopez and House Manager Maria Abaya 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 (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated office for resident/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (3) resident medications and (1) hospice file. During medication audit LPA Rico observed R1 PRN medications response and time were not documented. Furthermore, LPA also reviewed (3) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. Based on the observations made during today’s visit, (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809)(LIC809D) was discussed and provided to Administrator April Lopez.Along with a copy of appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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Document Has Been Signed on 03/20/2025 03:51 PM - It Cannot Be Edited


Created By: Mary Rico On 03/20/2025 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HAMNER MANOR

FACILITY NUMBER: 336423397

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not documenting R1 PRN response which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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The Administrator stated the facility will have an in-service training for staff, and will send a copy to LPA Rico
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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