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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530095
Report Date: 05/26/2023
Date Signed: 06/20/2023 10:29:33 AM

Document Has Been Signed on 06/20/2023 10:29 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:DIVINE MANOR CARE 2FACILITY NUMBER:
365530095
ADMINISTRATOR:YADAV, SHREETAFACILITY TYPE:
740
ADDRESS:544 W 9TH STREETTELEPHONE:
(347) 449-2449
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 6DATE:
05/26/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Administrator Shreeta YadavTIME COMPLETED:
01:40 PM
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Licensing Program Analysts (LPAs) Melody Brown and Mary Rico conducted an announced visit to the facility for purpose of a Change of Ownership evaluation. At approximately 10:00 AM, LPAs met with Administrator Shreeta Yadav . An initial application for change of ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 04/27/2023 for a total capacity of 6 with five (5) non-ambulatory and one (1) bedridden. Fire clearance was granted on 02/28/2023. LPAs Brown and Rico observed the following:
Structure:
Facility was a one (1)-story house with four (4 )resident bedrooms, one (1) resident and one (1) staff bathroom, living room, dining area and kitchen. There was an attached one car garage in the right backside of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each resident bedrooms accommodate five (5) non- ambulatory and one (1) bedridden resident. Three (3) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. However, one (1) resident bedroom have no closet.
Bathrooms:
The one (1) resident and one (1) staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. At 11:10 AM, LPAs tested the water temperatures in the resident bathrooms. LPAs verified water temperature was measured at 109 degrees Fahrenheit.
***CONTINUED ON LIC 809-C***

*** This is an amendment of the LIC809 issued last 05/26/2023 ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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 6
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: DIVINE MANOR CARE 2
FACILITY NUMBER: 365530095
VISIT DATE: 05/26/2023
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***CONTINUED FROM LIC 809***
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. LPAs observed residents medicine in unlocked kitchen drawer prepared ahead of time, in a predispensed container with resident name. LPAs requested Applicant Yadav to immediately remove and locked away the predispensed medications found in the unlocked drawer. There was adequate room for food storage. LPAs observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the garage. Laundry detergents and cleaning supplies were observed in garage, garage door is locked away from residents.
Living/Family room:
There was a living/family room with adequate seating for all residents and a working TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.
Yards/Outside:
Patio furniture for outdoor seating observed. Self-latching handle on right side of the house that leads into the backyard. There is a gate on the back right side with an exit in the front of the house. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the dining room and small hallway. There was Ombudsman poster and Let-Us-No poster observed.
General items:
Two (2) fire extinguishers were charged and located in the kitchen and resident bedroom. Eight (8) smoke alarms and one (1) carbon monoxide detector were tested and were observed to be in working order. Resident records were stored in a locked cabinet in the garage. First Aid kit with required components, and locked area for medication storage was observed. LPAs observed a facility phone and was operational as evidenced by LPAs dialing the number. The phone number designated for the facility is 909-727-8305. There is enough Emergency water supply observed but LPAs Brown and Rico observed no available required 72-hour emergency food supply and no available resident Emergency Bags at the facility. Component III was completed on this day as well.***CONTINUED ON LIC 809-C***
*** This is an amendment of the LIC809 issued last 05/26/2023 ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: DIVINE MANOR CARE 2
FACILITY NUMBER: 365530095
VISIT DATE: 05/26/2023
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***CONTINUED FROM LIC 809***

Additionally, LPAs observed facility to have required single entry point for COVID screening, upon entering facility. LPAs observed required COVID signages throughout the facility, soap and disposable towels in bathrooms for washing hands. LPAs observed incomplete Activity Calendar for the month for the residents.

Moreover, LPAs Brown and Rico observed no Rights of Resident Council Board and Family Council Board were posted in a prominent place at the facility.

Pre-Licensing is incomplete and the following deficiencies to be resolved by 06/20/2023 at 10:00 AM.
  • Obtain/Purchase 72-hour emergency food supply for residents
  • Obtain/Purchase 72-hour emergency bag pack for residents
  • Staff Medication Training with Staff Training Log (medications need to be in a locked drawer)
  • Purchase Closet for Resident #1 (R1) and Resident #5 (R5)
  • Post Rights of Resident Council Board
  • Post Family Council Board


An exit interview was conducted, and a copy of this report, LIC809 and LIC9102 TA were discussed and provided to Administrator Shreeta Yadav.



*** This is an amendment of the LIC809 issued last 05/26/2023 ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/20/2023 10:31 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/19/2023 05:02 PM


Created By: Melody Brown On 05/26/2023 at 12:31 PM
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: DIVINE MANOR CARE 2
FACILITY NUMBER: 365530095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

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 having residents predispensed medication in an unlocked drawer which poses an immediate health, safety or personal rights risk to persons in care. **** This deficiency will be deleted ******
POC Due Date: 05/27/2023
Plan of Correction
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Licensee stated to train all staff on Medication Administration and submit proof of Training Log to LPA Brown by POC due date. **** This deficiciency will be deleted ******
Licensee stated to submit signed Statement of Understanding on CCR 87309(b) and submit to LPA Brown by POC due date. **** This deficiency will be deleted ******
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023


LIC809 (FAS) - (06/04)
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