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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423954
Report Date: 03/10/2025
Date Signed: 03/10/2025 01:28:07 PM

Document Has Been Signed on 03/10/2025 01:28 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WASHINGTON FAMILY MANORFACILITY NUMBER:
366423954
ADMINISTRATOR/
DIRECTOR:		WASHINGTON, SIMONEFACILITY TYPE:
740
ADDRESS:2235N. ARROWHEAD AVETELEPHONE:
(909) 562-4101
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 6CENSUS: 3DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:42 AM
MET WITH:Simone Washington, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst, LaVette Farlow, (LPA) arrived at Washington Family Manor unannounced to conduct the facility's Annual Inspection. LPA rang the doorbell several times, made two calls, and stood outside for 5 minutes or more before being greeted and granted entry by Rachel Foster, Caregiver. Foster notified the Administrator Simone Washington, of my arrival. LPA introduced self and stated purpose of the visit. LPA was granted entry and provided space to work. LPA was then accompanied by Caregiver Foster on a tour of the facility grounds.

Facility: LPA was informed that the current census is 3. The facility is licensed 6 non-ambulatory residents. Dementia Care Plan in place. Hospice Waiver approval of 2 residents, and diabetic and glucose monitoring approved. LPA observed that the facility is operating at the capacity and in the conditions approved by Community Care Licensing (CCL).



Physical Plant: LPA Farlow observed the facility's temperatures to be comfortable. Sufficient lighting was provided by various lamps, fixtures and night-lights throughout the facility. LPA observed carbon monoxide and fire alarms throughout facility. Administrator reports the facility conducts fire and disaster drills on a monthly basis. Fire extinguishers were observed to be fully charged January 13, 2025. The facility back yard contained a shaded space and adequate seating. LPA observed the following tools out and unsecured on the patio a hammer, hand trowel, and tree trimmer. A deficiency was cited. Administrator agreed to remove during the visit. The facility maintains its laundry room, extra hygiene and Personal Protective Equipment and extra supplies secure in the attached garage. The Living Room and Dining Room included activities, adequate seating and sufficient lighting. Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WASHINGTON FAMILY MANOR
FACILITY NUMBER: 366423954
VISIT DATE: 03/10/2025
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LPA tested the water temperature and the water measure at 127.7 and 125.7, which is very hot and out of regulation. Administrator did provide a log for the testing of the water temperature. A technical violation issued.
Resident Rooms included all required furnishings such as beds with appropriate linens, night stand, adequate lighting and seating. The facility does maintain a room for staff where staff files, resident files and medications secure.

Food Service: LPA observed the facility's food supply included a variety of items such as eggs, bread, milk, salad, fresh fruits and vegetables. Kitchen pantry with canned goods all in good standing. The amount of nonperishable and perishable food is sufficient for number of residents in care. LPA observed that sharps, chemicals, cleaning supplies were kept in secure and inaccessible to residents in care.
Care & Supervision: Facility has sufficient care staff; who assist residents 24 hours and 7 days a week. Administrator reported that 1 staff member lives on facility grounds and herself or other staff assist daily as part time caregiver. A review of staff files revealed that all staff files contained verification of their annual training, criminal record clearance, health screenings, First Aid/CPR. The Administrator's Administrator Certificate was observed in compliance.
Resident Records: LPA reviewed resident files for updated Physician's Report's, Needs and Services and Admissions Agreements. LPA observed 2 out of 2 residents MARS were inconsistent and had discrepancy. 2 out of 2 residents MARS did not have medication listed, a loose pills, discontinued medication still showing as being administered and not on the MARS. A deficiency cited.
Signs / Poster Emergency Disaster Plan, Long Term Care Ombudsman, Administrator Certificate, Personal Rights and Facility Sketch, Facility License, SEE/SAY are posted in a prominent place.

Based on observations, staff interviews and record reviews, 2 deficiency and 1 technical violation will be cited to address the concerns. Exit interview conducted and copy of this report was provided to Administrator/Licensee Simone Washington.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/10/2025 01:28 PM - It Cannot Be Edited


Created By: Lavette Farlow On 03/10/2025 at 12:40 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WASHINGTON FAMILY MANOR
FACILITY NUMBER: 366423954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 not ensuring that all gardening tool and other tool are secured and locked away inaccessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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Licensee agrees to review the regulation and remove and secure all tool and ensure they are inaccessible to residents in care. Licensee also agrees to sign a statement acknowledging understanding of the regulation by POC date.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring the MARS records are accurate, and state each medication being issue is correct. Also LPA observed the MARS listed medication that is no longer being administratered but had an initial as being dispensed, and medication not listed that are being administratered which poses an immediate health, safety or personal right risk to persons in care.
POC Due Date: 04/10/2025
Plan of Correction
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Licensee agrees to complete a MARS training for herself and all staff to ensure and understand the requirement for dispensing medication for residents in care. Licensee agrees to complete a statement and a list of all staff completing this training by POC date.
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:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
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