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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880951
Report Date: 01/19/2022
Date Signed: 01/19/2022 12:47:15 PM

Document Has Been Signed on 01/19/2022 12:47 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:CHERRY & PINE GARDEN HOME CAREFACILITY NUMBER:
361880951
ADMINISTRATOR:MANGANGEY, GLORIA ANNEFACILITY TYPE:
740
ADDRESS:7610 I AVENUETELEPHONE:
(442) 800-5502
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 2DATE:
01/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Glory Anne MangangeyTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Stephanie Williams conducted an unannounced visit to the facility in order to conduct a required annual inspection, with an emphasis on infection control, due to the COVID-19 pandemic. LPA Williams identified herself to Administrator, Glory Anne Mangangey, who was also informed of the purpose of the visit. Mangangey confirmed that the facility currently has no COVID-19 positive cases. LPA Williams was screened for COVID-19 symptoms upon arrival.

During the inspection, LPA Williams interviewed Mangangey regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA Williams observed appropriate postings in the facility, including COVID-19 symptoms postings and visitation policies, which were in accordance with the Department's guidelines. LPA Williams observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA Williams observed that the facility staff were wearing 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 and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients 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 resident presents any COVID-19 symptoms.

Furthermore, LPA Williams observed that the facility appeared to be meeting most operational requirements. LPA Williams observed that all utilities and appliances were functioning properly and all passageways clear of obstruction, including emergency exits. The facility was equipped with sufficient food supply and emergency supplies. All areas of the facility, including client bedrooms and restrooms, appeared clean and in good repair. LPA Williams observed that medications and sharps were kept inaccessible to clients in care. However, LPA Williams did observe several cleaning supplies/disinfectants accessible to residents in care, such as
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2022
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 01/19/2022 12:47 PM - It Cannot Be Edited


Created By: Stephanie Williams On 01/19/2022 at 12:27 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: CHERRY & PINE GARDEN HOME CARE
FACILITY NUMBER: 361880951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed several cleaning supplies/disinfectants to be accesible to residents in care, which poses a potential health and safety risk to persons in care.
POC Due Date: 01/26/2022
Plan of Correction
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POC cleared at the time of visit. The Administrator removed the items from resident access during the visit.
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:Stephanie Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2022


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CHERRY & PINE GARDEN HOME CARE
FACILITY NUMBER: 361880951
VISIT DATE: 01/19/2022
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bleach under a common restroom sink and in the facility's backyard.

Based on interviews and observations made during today’s inspection, one deficiency was 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 provided to Mangangey at the conclusion of the inspection.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
LIC809 (FAS) - (06/04)
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