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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800218
Report Date: 10/17/2024
Date Signed: 10/17/2024 11:26:57 AM

Document Has Been Signed on 10/17/2024 11:26 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SHOWERS OF BLESSINGS ADULT HOME "LLC"FACILITY NUMBER:
331800218
ADMINISTRATOR/
DIRECTOR:
KIPLEY, BRUCE D.FACILITY TYPE:
735
ADDRESS:6247 STOVER AVENUETELEPHONE:
(951) 525-3777
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 6CENSUS: 4DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Bruce D.KipleyTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Beena Singh and Paola Guerrero conducted an unannounced required 1-year visit to the facility. LPAs met with Bruce Kipley, Administrator and discussed the purpose of the visit. The facility is an Adult Residential Facility (ARF) Level 4, license capacity of (6) with a current census of (3) clients. (2) clients were attending the day program and (1) client were at the facility during LPAs visit. LPA Beena Singh conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: LPA Beena Singh inspected the facility inside and out. Indoor and outdoor passageways are kept free of obstruction.The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and shaded outdoor space for client activities. LPA Beena Singh observed books, board games, and art supplies for indoor LPA Beena Singh inspected the kitchen.

Yards/Outside: Indoor and outdoor passageways are kept free of obstruction. Facility has no bodies of water. Facility backyard is fenced and has self-latching gate. Facility outdoor patio furniture are in good repair and sufficient for clients in care.

Food Service: LPA Beena Singh observed facility has sufficient non-perishable and perishable food for number of clients in care. Facility food is stored in a safe and healthful manner. Facility has sufficient cups, plates, and utensils for client use. Sharps, disinfectants, and chemicals are kept locked and inaccessible to clients in care. LPA Beena Singh inspected client bedrooms. Bedrooms are equipped with beds, bed linen, night-stands, chairs, sufficient storage space, and sufficient lighting. LPA Beena Singh inspected client bathrooms. Bathroom equipment is operating in a safe and sanitary manner.Hot water temperature tested at 109 degrees F.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SHOWERS OF BLESSINGS ADULT HOME "LLC"
FACILITY NUMBER: 331800218
VISIT DATE: 10/17/2024
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Food Service: LPA Beena Singh observed facility has sufficient non-perishable and perishable food for number of clients in care. Facility food is stored in a safe and healthful manner. Facility has sufficient cups, plates, and utensils for client use. Sharps, disinfectants, and chemicals are kept locked and inaccessible to clients in care. Refrigerator and freezers have temp within required limits.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

The facility is equipped with operating carbon monoxide alarms and telephone service. The last fire drill was conducted on 7/1/24. LPA Beena Singh observed poster posted in a common area: personal rights and evacuation plan and emergency numbers. The facility has complete first aid kit and emergency supplies. The facility has a sufficient supply of bed linen, towels, and hygiene products for clients in care. LPA medications for (3) clients. Medications are labeled and administered as prescribed. Medications are kept safe in a locked cabinet and inaccessible to clients in care.

Records Review: LPA Beena Singh reviewed (3) client files for emergency contacts, admission agreements, Individual Program Plan (IPPs), physician reports and safe guarded resources; all had the required documentation. LPA Beena Singh reviewed (3) staff files for criminal record clearances, first aid certifications, training, and health screenings, personnel records; all had the required documentation. Medications were audited at random and appeared to be dispensed appropriately by staff members, locked & stored in cabinet.

No deficiencies were cited during today’s visit.

An exit interview was conducted, where this report was discussed, and a copy was provided to the Administrator Bruce Kipley at the conclusion of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
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