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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880951
Report Date: 01/13/2025
Date Signed: 01/13/2025 03:39:30 PM

Document Has Been Signed on 01/13/2025 03:39 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:CHERRY & PINE GARDEN HOME CAREFACILITY NUMBER:
361880951
ADMINISTRATOR/
DIRECTOR:		MANGANGEY, GLORIA ANNEFACILITY TYPE:
740
ADDRESS:7610 I AVENUETELEPHONE:
(442) 800-5502
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 3DATE:
01/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Gloria Anne MangangeyTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Gloria Anne Mangangey and discussed the purpose of the visit.

The facility is a 3 bedroom, 3 bathroom, Residential Care Facility for the Elderly (RCFE) with a license capacity of (6) and a current census of (3) residents in care. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor shaded area is sufficient for resident activities and is enclosed with a self-latching gate. LPA observed saws and tools in an unlocked outdoor shed. The facility has sufficient lighting, books, magazines, games, and activity space for residents. The facility is maintained at 72 degrees F. Resident’s bathrooms equipment were fully operational and bathrooms were equipped with grab rails and slip mats. The hot water temperature in residents' bathrooms measured 105 degrees F. The facility maintains an operating night light in hallway leading to central bathroom. Resident’s bedrooms audited had sufficient lighting, bed linen and furniture in good repair. The facility is equipped with carbon monoxide alarms, fully charged fire extinguishers, laundry equipment, signal system and telephone service. The facility has sufficient bed linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, Personal Rights, facility license, disaster evacuation plan and emergency telephone numbers. Sharp knives and scissors were kept lock. LPA observed disinfectant and insecticide sprays were stored unlocked in the bathroom located near the kitchen area. LPA observed disinfectant cleaning wipes on bathroom counter in bedroom #1, accessible to residents in care.

Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. The facility has sufficient clean cups, plates, and utensils for residents use.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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 01/13/2025 03:39 PM - It Cannot Be Edited


Created By: Magda Malcore On 01/13/2025 at 01:48 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: 01/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by not ensuring disinfectants, cleaning wipes, saws, and tools; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Staff locked disinfectants, insecticides, and outside shed during the visit.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care 87465(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation , the licensee did not comply with the section cited above by not maintaining resident's medication in their orginal container with prescription label;which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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The Licensee shall conduct inservice medication management training with staff and submit proof of training to the licensing agency by POC due date.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025


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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CHERRY & PINE GARDEN HOME CARE
FACILITY NUMBER: 361880951
VISIT DATE: 01/13/2025
NARRATIVE
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Care & Supervision: Facility has 24-hour, 7 days a week care staff. Staff working have criminal records clearances through the Department.

Record Review: The facility's Administrator certification and liability insurance is current. Staff files reviewed were observed to be complete. Review of resident files reveals resident #1 (R1) and resident #2 (R2) did not have a reappraisal conducted within the last 12 months.

Medical Related Services: Resident’s medications are centrally stored in a locked cabinet. The facility has a complete first aid kit with manual. LPA observed R1, R2, and resident#3 (R3)'s pm medication was missing from the bubble packet. Staff stated that the medication was removed from the packet and showed LPA the medication was stored in a small plastic container. LPA observed R3's insulin pin was kept in plastic bag separated from its original prescription packaging.

Based on observations and record review, deficiencies are being cited and technical advisories were issued per Title 22, of The California Code of Regulations.

This report and correction plans were reviewed with the Administrator and copies with Appeal Rights were provided at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/13/2025 03:39 PM - It Cannot Be Edited


Created By: Magda Malcore On 01/13/2025 at 02:34 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: 01/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals 87463(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA review review, the licensee did not comply with the section cited above by not maintaining a current reappraisal for R1 and R2 on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
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The Licensee shall submit to the licensing agency an current appraisal for R1 and R2 by POC due date.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025


LIC809 (FAS) - (06/04)
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