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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530075
Report Date: 12/20/2022
Date Signed: 12/20/2022 12:07:03 PM

Document Has Been Signed on 12/20/2022 12:07 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CANYON VIEW COUNTRY HOMEFACILITY NUMBER:
365530075
ADMINISTRATOR:CREIGHTON, IRENFACILITY TYPE:
740
ADDRESS:418 HASTINGS ST.TELEPHONE:
(909) 548-1769
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY: 6CENSUS: DATE:
12/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Iren Creighton, AdministratorTIME COMPLETED:
12:10 PM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Canyon View Country home to conduct the Pre-Licensing Visit. Application submitted 11/6/22. Fire Clearance was approved on 11/23/22. Facility is approved for a capacity of 6.1 Ambulatory, 4 Non Ambulatory and 1 Bedridden. Fire Clearance approved for 1 bedridden resident in rooms 2 and 3 only. LPA introduced self to facility staff members Iren Creighton, Administrator and Nick Vermani, Licensee and stated the purpose of the visit. LPA was invited inside. Upon walking in door. LPA observed infection control signs posted both inside and outside front door. COVID station observed near the door offering visitors, staff and residents PPE and hand sanitizer.

The facility is one story and comprised of 4 rooms. 2 living room spaces, 1 dining room, 3 Bathroms, a laundry room and attached garage.

Client Rooms equipped with one or 2 beds, sufficient lighting and furnished with night stand and chair. extra linens were observed inside of each closet. Night lights were observed in resident rooms and along the baseboards through out the facility.

Client Bathrooms fit to accommodate ambulatory and non-ambulatory residents. Each containing sufficient hygiene and paper products.

**Continued on LIC809-C**
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CANYON VIEW COUNTRY HOME
FACILITY NUMBER: 365530075
VISIT DATE: 12/20/2022
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Kitchen and Dining Rooms: Kitchen observed to be fully stocked with adequate food for the capacity of residents. Space for sharp objects was designated for a secure cabinet. Chemicals designated to be kept under the sink in a secure cabinet. LPA observed adequate dishes and silverware. Emergency supply of food will be kept secure in garage.
Dining rooms were observed to be orderly and offering adequate seating for residents.

Common Sitting Areas: There is adequate seating and space in the common areas made available to residents and family to visit.

Laundry Room: The area is secured near the facilities second entrance. Also, contained a secure place for laundry detergent.

Backyard: No bodies of water observed on premises. Administrator shared that the ramps for residents was just poured. All passageways were free from obstruction. All resident windows were observed to be intact, free of insects or debris.

LPA and Licensee observed a wall with a number of secure cabinets. Licensee explained that their plan to keep resident medications, resident and staff files in these cabinets. As well as extra PPE.

A total of 3 fire extinguishers were located throughout facility. Last inspection date was 11/23/22. Fire and Carbon Monoxide alarms were tested and found to be operational.

LPA observed required postings including the visitation polices, emergency/disaster plans, and personal rights. The facility was equipped with a complete first aid kit and manual. The water temperature was tested and observed to be between 105-108 degrees Fahrenheit.

LPA observed that the physical plant is clean, in good repair, and appear to be hazard-free during today's visit. LPA has determined that the facility is meeting operational requirements for potential resident. LPA completed COMP III with Licensee at the conclusion of the inspection. The pre-licensing inspection is complete and this facility has no deficiencies. Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy was provided to Nick Vermani.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC809 (FAS) - (06/04)
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