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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881284
Report Date: 03/06/2025
Date Signed: 03/06/2025 11:47:31 AM

Document Has Been Signed on 03/06/2025 11:47 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KWIK ELDERLY ESTATEFACILITY NUMBER:
361881284
ADMINISTRATOR/
DIRECTOR:		ZEBEDEUS, MOODYFACILITY TYPE:
740
ADDRESS:25615 STATE STREETTELEPHONE:
(909) 492-1609
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 6CENSUS: 6DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:House Manager Nita ManuripTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with House Manager Nita Manurip, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (6). 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 does not have a swimming pool or similar bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities. The facility is equipped with operating smoke detectors/carbon monoxide alarms, working laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in two (2) resident bathrooms measured between 110.6 and 115.3 degrees F. Four (4) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, administrator certificate, facility sketch, residents personal rights, emergency disaster plan and telephone numbers, CCLD complaint poster, and Ombudsman poster.

Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps and chemicals were kept locked and inaccessible to residents in care.

Continuation on LIC – 809C:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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 03/06/2025 11:47 AM - It Cannot Be Edited


Created By: Sarina Ramirez On 03/06/2025 at 10:54 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: KWIK ELDERLY ESTATE
FACILITY NUMBER: 361881284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having refridgerated medication locked inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Adminstrator has relocated refigerated medication to refrigerator in the garage that is kept locked and inaccessible to residents in care.
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:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KWIK ELDERLY ESTATE
FACILITY NUMBER: 361881284
VISIT DATE: 03/06/2025
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Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff have current CPR/first aid training.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet, however refrigerated medication was not locked; Administrator relocated medication; deficiency issued.

Record Review: Three (3) Staff files reviewed were observed to be complete. Four (4) Resident files reviewed were observed to be complete.

Based on observations and record review one (1) deficiency and Technical assistance was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report along with LIC 809D, LIC 902, and Appeal Rights were discussed and provided to House Manager Nita Manurip.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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