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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604496
Report Date: 04/24/2024
Date Signed: 04/24/2024 03:28:08 PM

Document Has Been Signed on 04/24/2024 03:28 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ARNICARE VILLAFACILITY NUMBER:
374604496
ADMINISTRATOR/
DIRECTOR:
MONTAZER, ARNIFACILITY TYPE:
740
ADDRESS:1044 JESSICA LANETELEPHONE:
(858) 382-1568
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 5DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Arni Montazer, TIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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On 04/24/24 Licensing Program Analyst (LPA) Javina George conducted an unannounced 1 year required visit. LPA met with Administrator Arni Montazer. The facility is licensed for 5 non-ambulatory residents and 1 bedridden resident. The facility does not have a resident that is bedridden at this time. The facility has an approved hospice waiver for six (6), there are zero (0) residents receiving hospice services at this time. At the time of the visit there were four (4) residents and four (4) staff present. All staff were observed to have obtained criminal record clearance and are associated to the facility.

LPA conducted a tour of interior and exterior of the facility. The facility was observed to be clean, clutter and odor free. The facility was observed to have a 2 day supply of perishable and a 7 day supply of non perishable food items. The carbon monoxide and smoke detectors were tested and were observed to be operable. The emergency disaster drills are being conducted on a quarterly basis, the last drill was conducted on 3/30/24. There are no known guns or ammunition on the premises. The facility utilizes video surveillance in the common areas. There is a secured/locked gated pool inside the backyard, with a shaded area for sitting. The facility has activities available for residents to promote socialization.

Hazardous items such as, cleaning and disinfecting supplies are locked inside cabinets located inside of the laundry room. The knives, and other sharps are locked and inaccessible to residents inside a drawer inside of the kitchen across from the refrigerator. The medications are locked inside a closet next to bedroom #1 that requires a code to be entered on a key pad in order to entry/access.

LPA conducted a review of resident files and observed for the required documentation such as the Emergency Identification form, Admission agreement video surveillance acknowledgment form, appraisals needs and services plan to be present.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ARNICARE VILLA
FACILITY NUMBER: 374604496
VISIT DATE: 04/24/2024
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LPA conducted a review of staff files which are all housed in one binder. The staff were observed to have received their initial and annual training's, as well as possess current Cardio Pulmonary Resuscitation (CPR) cards. The Administrator certificate expires on 8/12/24.

Based on today's inspection there were no deficiencies observed.

An exit interview was conducted and a copy of this report was provided to Administrator Arni Montazer.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC809 (FAS) - (06/04)
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