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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880539
Report Date: 06/21/2023
Date Signed: 06/21/2023 01:45:40 PM

Document Has Been Signed on 06/21/2023 01:45 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:ROBINSON RANCH ADULT HOME IIFACILITY NUMBER:
331880539
ADMINISTRATOR:ROBINSON, OLGAFACILITY TYPE:
735
ADDRESS:1260 PASEO GRANDE RDTELEPHONE:
(951) 340-3127
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 6CENSUS: 5DATE:
06/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Olga Robinson- LicenseeTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Victoria Chitgian arrived unannounced to conduct a visit to the facility for a required annual inspection. Facility is an Adult Residential Facility licensed for six (6) clients, four(4) of non-ambulatory status. LPA met with Licensee, Olga Robinson at the facility.
LPA conducted a walk-through the facility's interior and exterior. The facility has a charged fire extinguisher, operating fire alarm systems, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review and included nutritious options. LPA toured the client bedrooms. The client bedrooms had functional lighting and required furniture. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 5/30/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Cleaning supplies were stored in the garage locked away. Centrally stored medications were kept in a safe and locked cabinet. Sharps were stored in a secured area. LPA toured the bathrooms and kitchen. Hot water temperature was measured in the bathrooms and was found within required limits at 118 degrees Fahrenheit. The outside of the facility had a shaded area with seating for client comfort. The facility does not have bodies of water.
LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA inspected client medications. Medications were dispensed appropriately according to the physician's orders.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2023
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: ROBINSON RANCH ADULT HOME II
FACILITY NUMBER: 331880539
VISIT DATE: 06/21/2023
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Licensee has secured each consumer’s personal property and cash resources. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care. All required postings were visible in a common area. During the visit, licensee was informed of the facilities outstanding balance for licensing fee’s in the amount of $682.00. LPA stated will send a follow up email.

No deficiencies were issued during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to the Licensee Olga Robinson at the end of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC809 (FAS) - (06/04)
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