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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800198
Report Date: 11/03/2021
Date Signed: 11/03/2021 03:59:13 PM

Document Has Been Signed on 11/03/2021 03:59 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MGB CARMEL MANORFACILITY NUMBER:
361800198
ADMINISTRATOR:BERNAL, GLENNFACILITY TYPE:
740
ADDRESS:457 WEST 13TH STREETTELEPHONE:
(909) 982-4786
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 6DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Ranulfa RegisTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPAs) Anna Bueno and Bernadette Allen made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA met with staff Ranulfa Regis and Eladia Plenos who confirmed that there are currently no cases/exposures of COVID-19 within the facility. Administrator Glenn Bernal was phoned by staff but was not able to come to the facility.

During the inspection, LPAs Allen and Bueno conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. LPAs observed live in staff members were not fitted with face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the client presents any COVID-19 symptoms.

LPAs Allen and Bueno observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed and a copy of this report was also provided to Ranulfa Regis at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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