365530028-9-14-2022-56-AS-RLAA-CJ9MNE-20220914094526

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530028
Report Date: 09/14/2022
Date Signed: 09/14/2022 09:45:34 AM

Document Has Been Signed on 09/14/2022 09:45 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	MADRONA MANOR		FACILITY NUMBER:	365530028
ADMINISTRATOR:	KAUR, GULVARG		FACILITY TYPE:	740
ADDRESS:	821 EAST MADRONA STREET		TELEPHONE:	(909) 341-5084
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY: 6		CENSUS: 0	DATE:	09/14/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Gulvarg Kaur, Administrator		TIME COMPLETED:	10:00 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

At 8:55 AM on 09/14/2022, Licensing Program Analyst (LPA) Rohit Lama conducted an unannounced visit to the pending facility for a pre-licensing inspection. LPA met with Gulvarg Kaur, Administrator.

This facility was previously licensed as St. Christopher Villa (Facility Number: 366 400 931) and is undergoing a change of ownership. The pending application is for a capacity of six (6) residents: five (5) non-ambulatory residents and one (1) bedridden resident in a Residential Care Facility for the Elderly (RCFE).

Fire clearance was granted by the San Bernardino County Fire Department for five (5) non-ambulatory residents and one (1) bedridden resident. There are charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. Emergency disaster plans, personal rights, and the Community Care Licensing poster were posted in a prominent area. The facility was equipped with a complete first aid kit and manual as well as emergency supplies.

LPA toured the facility inside and out. The following was observed, reviewed, and inspected:

The facility has 5 bedrooms, 4 of which are to be used for residents and one is to be used for staff. The facility also has 2 bathrooms, living room, kitchen, dining area, great room, laundry room, backyard, and attached garage.

The physical plant, in general, was in good repair. The buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. LPA inspected the backyard. LPA observed. There was a shaded area with seating. There was no obstruction on the side yard exits. The gates remained unlocked.

***CONTINUED ON LIC 809-C***

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MADRONA MANOR	FACILITY NUMBER: 365530028
	VISIT DATE: 09/14/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

***CONTINUED FROM LIC 809***

LPA was informed that no firearms or ammunition will be kept at facility. The Administrator has a current Administrator's Certificate with an expiration date of: 07/01/2023.

LPA inspected resident bedrooms. Resident bedrooms have the required bedding and furniture. All bedrooms included clean mattresses, closet space, nightstands, dressers, and sufficient lighting. LPA inspected resident bathrooms. The bathrooms were operating in safe and sanitary conditions. The bathroom had soap and disposable towels in bathrooms for washing hands. LPA measured the hot water temperature, which measured within regulation at 109 degrees F. LPA also observed additional linen and hygiene items for the residents. LPA toured the kitchen. The facility had a 2-day supply of perishable food items and 7-day supply of non-perishable food items. The food was labeled with expiration dates and stored in a safe and healthful manner. The facility had a menu available for review. Dishes, glasses, and utensils were in good condition.

There was a locked and centralized storage area for medications. Cleaning supplies, toxins, and sharps were kept locked away and inaccessible to residents. Additionally, LPA observed facility to have required single entry point for COVID screening, upon entering facility. LPA observed required signages throughout the facility for COVID, Visitation, resident rights, along with other signs required by the department.

The facility had a designated area for resident and staff files, which was locked. The facility had working telephones for residents’ use. There was adequate seating in the common areas. LPAs observed activities for the residents such as books and games.

The facility was evaluated in accordance with Title 22, Division 6, Chapters 1 to ensure the health and safety of residents in care and meets regulation guidelines. At this time facility has shown to have met pre-licensing requirements. No corrections are needed.

An exit interview was conducted, and a copy of this report (LIC 809) was reviewed with and provided to the Administrator.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2