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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881048
Report Date: 11/08/2024
Date Signed: 11/08/2024 12:15:17 PM

Document Has Been Signed on 11/08/2024 12:15 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AQUA RIDGE OF MONTCLAIRFACILITY NUMBER:
361881048
ADMINISTRATOR/
DIRECTOR:		MONIQUE DEL JUNCOFACILITY TYPE:
740
ADDRESS:9631 MONTE VISTA AVETELEPHONE:
(909) 483-2782
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY: 115CENSUS: 71DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Monique Del Junco, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 11/08/2024 at 09:00 AM, Licensing Program Analysts (LPAs) Eldin Serrano and Sarina Ramirez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPAs met with Executive Director Monique Del Junco and was granted entry to the facility. At the time of the visit there was two (2) staff present.

The facility is a one hundred five (105) bedrooms, seventy eight (78) bathrooms facility with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of one hundred fifteen (115) non-ambulatory and twelve (12) hospice care and twelve (12) maybe bedridden resident and the current census is seventy one (71) residents. LPAs were accompanied by Resident Care Director Jonathan Rios to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. LPAs inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. LPAs measured and observed the water temperatures in the bathroom to be at 117 degrees Fahrenheit at Room #106. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, labor laws, and the disaster plan were posted in a common area.

***Continuation in LIC809C ***

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AQUA RIDGE OF MONTCLAIR
FACILITY NUMBER: 361881048
VISIT DATE: 11/08/2024
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LPAs observed that cleaning supplies, toxins, sharps, and other dangerous items were not kept in a secure area or locked cabinets accessible to residents in care. Deficiency will be issued. There was a designated storage space for resident/staff files. There is a Medicine Room with the resident’s medications locked. LPAs Serrano and Ramirez observed complete first aid kit and first aid book at the facility.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has an Executive Director present in the facility with appropriate and enough hours to appropriately manage the facility.

Record Review: LPAs reviewed five (5) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPAs observed resident files reviewed were complete. LPAs reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications/Medication Administration Record (MAR) were audited and found no issue.

Based on the observations made during today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D forms, and Appeal Rights were discussed and provided to Executive Director Monique Del Junco.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2024 12:15 PM - It Cannot Be Edited


Created By: Eldin Serrano On 11/08/2024 at 11:57 AM
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: AQUA RIDGE OF MONTCLAIR
FACILITY NUMBER: 361881048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 by not ensuring that cleaning supplies, toxins, sharps, and other dangerous items were kept in a secure area or locked cabinets inaccessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2024
Plan of Correction
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Licensee stated that they will submit proof of correction on the above cited deficiency by the plan of correction (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:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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