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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530028
Report Date: 08/16/2022
Date Signed: 08/16/2022 01:52:24 PM

Document Has Been Signed on 08/16/2022 01:52 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, 744 P STREET, MS 9-14-8201
, CA 95814
FACILITY NAME:MADRONA MANORFACILITY NUMBER:
365530028
ADMINISTRATOR:KAUR, GULVARGFACILITY TYPE:
740
ADDRESS:821 EAST MADRONA STREETTELEPHONE:
(909) 341-5084
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 0DATE:
08/16/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Gulvarg Kaur, AdministratorTIME COMPLETED:
01:50 PM
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Component II Completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Gulvarg Kaur, Administrator
Interview Method: Telephone interview

On August 16, 2022 at 1:00 PM, Administrator participated in COMP II. Identification of the Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB Analyst confirmed Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Administrator. Report sent via email pdf and informed Administrator to return signed copy by close of business today.
SUPERVISORS NAME: Joshua Miller
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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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