<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800198
Report Date: 11/22/2022
Date Signed: 11/22/2022 09:44:52 AM

Document Has Been Signed on 11/22/2022 09:44 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: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: 5DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator Glenn BernalTIME COMPLETED:
09:55 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Victoria Chitgian 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 was greeted by caregiver Eladia Plenos and met with Administrator Glenn Bernal. At the time of the visit there were three (3) staff, and five (5) residents present.

LPA discussed best practices for infection control and prevention and toured the facility inside and outside. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating residents and caring for residents with COVID-19 positive results and/or exposures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases, 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 entrance of the facility has a check in process for staff and visitors that includes a temperature and symptom check. The bathrooms were stocked with hand soap and paper towels. Postings are seen throughout the facility for proper cough etiquette, proper hand washing procedure, and social distancing guidelines. LPA requested to inspect the facility's Personal Protective Equipment (PPE) supplies, which were in the hallway closet. The facility has a full thirty (30) day supply of PPE items including gloves, gowns, disinfectant, surgical masks, N95 masks, and hand sanitizer available.

All staff and residents are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA toured the facilities interior and exterior and there were no health and safety concerns.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MGB CARMEL MANOR
FACILITY NUMBER: 361800198
VISIT DATE: 11/22/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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) was discussed and provided to Administrator Glenn Bernal.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2