331880500-6-1-2023-56-AS-MMAE-CSDU37-20230601151304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880500
Report Date: 06/01/2023
Date Signed: 06/01/2023 03:13:15 PM

Document Has Been Signed on 06/01/2023 03:13 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:	DUFFERIN HOME INC, THE		FACILITY NUMBER:	331880500
ADMINISTRATOR:	FURDUI, LIDIA		FACILITY TYPE:	735
ADDRESS:	10348 BROOKWAY PL		TELEPHONE:	(951) 324-1803
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92505
CAPACITY: 6		CENSUS: 6	DATE:	06/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Lidia Furdui, Administrator		TIME COMPLETED:	03:15 PM

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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Lidia Furdui, Administrator, and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), license capacity of (6) with a current census of (6). The facility has (4) client bedrooms, (1) staff room, (2) bathrooms, kitchen/dining area, living room, and attached garage. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. Facility has no outdoor bodies of water. The facility has sufficient indoor and outdoor furniture in good repair for clients in care. Facility has a covered outdoor patio area with furniture in good repair and sufficient for clients in care. Self-latching gated back yard. The facility has sufficient lighting and is maintained at a comfortable temperature 73 degrees F.

LPA inspected the kitchen. Facility has sufficient non-perishable and perishable food for the number of clients in care. A monthly menu is posted in the kitchen. Facility food is stored in a safe and healthful manner. Facility has sufficient cups, plates, and utensils for clients in care. Sharps are are kept locked and inaccessible to clients in care. Kitchen hot water tested within regulation at 105 degrees F.

LPA inspected client bedrooms. Bedrooms are equipped with required furniture in good repair such as: mattresses, nightstands, pillows, and storage space. Bedrooms have sufficient linen and lighting.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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: DUFFERIN HOME INC, THE	FACILITY NUMBER: 331880500
	VISIT DATE: 06/01/2023

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LPA inspected client bathrooms. Bathrooms are equipped with handrails and operating in safe and sanitary conditions. The hot water temperature tested within regulation at 113 degrees F.

LPA observed the facility is equipped with operating carbon monoxide alarms and fully charged fire extinguishers. Facility has operating telephone service. Posters such as personal rights, complaint telephone number, emergency phone numbers are posted in a common area. Emergency drill conducted on 5/09/23. Cleaning supplies, toxins, items are kept locked and inaccessible to clients in care.

Client medications are kept in a safe and locked cabinet inaccessible to clients in care. All medication are labeled and administered as prescribed.

All staff files reviewed had criminal record clearance, First Aid/CPR, training certifications, and health screenings. All files had the required documents.

All client records reviewed had admissions agreements, updated physician's report, personal rights statements, needs and service plans.

Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. No deficiencies were cited during today's visit.

An exit interview was conducted, where this report (LIC809) was discussed and a copy of report with appeal rights was provided to the Administrator at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

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