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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881019
Report Date: 02/13/2024
Date Signed: 02/13/2024 02:54:51 PM

Document Has Been Signed on 02/13/2024 02:54 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:WILDWOOD CANYON VILLAFACILITY NUMBER:
361881019
ADMINISTRATOR:BARRERA, WENDYFACILITY TYPE:
740
ADDRESS:33951 COLORADO STTELEPHONE:
(909) 446-0405
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 130CENSUS: 61DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Wendy Barrera, AdministratorTIME COMPLETED:
03:00 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 Wendy Barrera, Administrator, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (130) and a current census of (61) residents in care. The facility has a hospice waiver for (20) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. The facility's outdoor activity areas are enclosed and sufficient for resident activities. The facility's indoor activities areas are sufficient for residents activities. Five (5) resident bathrooms inspected were maintained in operating and sanitary conditions. In resident's bathrooms, the lowest hot water temperature tested 106 degrees F and the highest hot water temperature tested 116 degrees F. Five (5) resident bedrooms inspected have sufficient lighting, operating signal system, and furniture in good repair. The facility has operating fire and carbon monoxide alarms, laundry equipment, and telephone service. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Ombudsman poster, resident council rights, monthly planned activities, emergency evacuation exits and emergency telephone numbers.

Care & Supervision: Facility has 24-hour care staff to meet the needs of the residents.

Medical Related Services: All medication is centrally stored and kept locked in the medication room.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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 9
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: WILDWOOD CANYON VILLA
FACILITY NUMBER: 361881019
VISIT DATE: 02/13/2024
NARRATIVE
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Food Service: The facility kitchen is maintained free of litter and pests. The facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas. The facility's dining room areas are sufficient for residents in care.

Record Review: The last fire drill conducted was on 1/30/24. The facility's liability insurance is current. Five (5) resident files reviewed were observed to be complete. Review of five (5) staff files reveal the following: staff #1(S1), staff #2(S2), staff #3(S3), staff #4(S4), and staff #5 (S5) did not have documentation of criminal record clearances on file. S1, S2, S3, and S4 did not have documentation of First Aid training on file. S1 did not have documentation of job related training on file. S4 did not have documentation of a health screening with tuberculosis results on file. Deficiencies cited.

Based on observations and record review, deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations

An exit interview was conducted where Licensing reports LIC809, LIC809-C, LIC809-D, and LIC9102 were discussed. Copies of the reports with Appeal Rights were provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 02/13/2024 02:54 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/13/2024 at 01:41 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: WILDWOOD CANYON VILLA
FACILITY NUMBER: 361881019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(13)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA file review, the licensee did not comply with the section cited above by not maintaining record of staff #1(S1), staff #2(S2), staff #3(S3), staff #4(S4), and staff #5 (S5) criminal record clearances on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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The Licensee/Administrator shall submit to the licensing agency a statement of understanding of the cited regulation.
Type B
Section Cited
CCR
87411(f)
Criminal Record Clearance
Personnel Requirements (f) All personnel...shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician...This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA record review, the licensee did not comply with the section cited above by not maintaining documentation of S4's health screening with tuberculosis results on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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The Licensee/Administrator shall submit to the licensing agency proof of S4's tuberculosis results 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: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 02/13/2024 02:54 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/13/2024 at 01:41 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: WILDWOOD CANYON VILLA
FACILITY NUMBER: 361881019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA record review, the licensee did not comply with the section cited above by not maintaining documentation of staff #1 (S1) job related training on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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The Licensee/Administrator shall submit to the licensing agency proof of staff mentioned above, job related training.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA file review, the licensee did not comply with the section cited above by not maintaining documentation of staff #1(S1), staff #2(S2), staff #3(S3), and staff #4(S4) first aid training on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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The Licensee/Administrator shall provide proof of the staff mentioned above updated first aid training 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: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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