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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530028
Report Date: 12/19/2022
Date Signed: 12/19/2022 10:48:25 AM

Document Has Been Signed on 12/19/2022 10:48 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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: DATE:
12/19/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jiffrey "Niko" DeJose, CaregiverTIME COMPLETED:
10:50 AM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Madrona Manor Facility to conduct a Post Licensing visit as the facility has undergone a change of ownership. LPA introduced self to staff and explained the purpose of the visit. LPA was greeted and invited inside of the facility. Staff introduced themselves as Jiffrey "Niko" DeJose (S1). LPA signed in and had temperature taken. While signing in LPA observed a COVID station near the sign in sheet. The station included hand sanitizer, PPE and masks made available to staff, residents and visitors. Extra PPE was located inside of the COVID station. The facility was observed to be clean, orderly and in comfortable temperature. S1 contacted the Administrator to notify them of LPA's visit. Administrator arrived to facility during the visit.

LPA and S1 completed a walk through the facility. Signs for infection control, house rules and licensing were observed posted throughout facility. S1 reported the current census is three. At this time, there is no one diagnosed with COVID. Each bathrooms contained a supply of hand soap and paper supplies. LPA observed 3 residents in care during the visit; who all appeared comfortable and friendly demeanor.

In the kitchen, LPA observed that sharp objects are kept secure in a lock box. Chemicals are kept secure under the sink. Medications are kept secure in a closet adjacent to the kitchen. Medications that require refrigeration are kept secure in a small refrigerator. FIre and carbon monoxide alarms were tested and found operational. Fire extinguishers last inspected 6/2/22. Emergency food supply was located in the garage secure. LPA also observed extra cleaning supplies and PPE kept secure in the garage. A review of client files were found to be completed and well organized.

The facility was evaluated in accordance with the Title 22, California Code of Regulations (CCR). Based on the observations and evaluation of the facility this date, no deficiencies issued.

An exit interview was conducted, and a copy of this report (LIC 809) was discussed and provided with Administrator Gulvarg Kaur.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2022
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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