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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880753
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:20:38 PM

Document Has Been Signed on 11/07/2024 03:20 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:JHEHAN FAITH LLCFACILITY NUMBER:
331880753
ADMINISTRATOR/
DIRECTOR:		TAGUBA, JENNIFER BFACILITY TYPE:
740
ADDRESS:5256 SIERRA VISTA AVENUETELEPHONE:
(717) 330-9409
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 6CENSUS: 3DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Licensee/Administrator Heldo TagubaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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 Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Beena Singh met with a staff, was granted entry to the facility. At the time of the visit there were three (3) staff present, and three (3) residents present. Licensee/Administrator Heldo Taguba was contacted and arrived during the visit.

The facility is a five (5) bedroom, two (2) bathroom home with a kitchen/dining area, living room and detached garage/stock room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which (6) can be non-ambulatory residents and one (1) may be bedridden resident. The facility has six (6) Hospice Waiver. The current census is three (3) residents. LPA Beena Singh was accompanied by Licensee/Administrator Taguba (S1) to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). LPA Beena Singh observed no obstructions to outdoor passageways. The facility is maintained at a comfortable temperature. LPA Beena Singh inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night-stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Beena Singh observed grab bars and customized tiles that functions as non-skid mat or strips in the resident bathrooms. Moreover, during the tour of the facility, LPA Beena Singh observed the knives drawer was locked in the kitchen and not accessible to residents in care. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the kitchen. Also, LPA Beena Singh observed a complete first aid kit maintained and readily available at the facility.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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 2
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: JHEHAN FAITH LLC
FACILITY NUMBER: 331880753
VISIT DATE: 11/07/2024
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LPA Beena Singh measured and observed the water temperatures in the bathroom to be at 109 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster and the disaster plan, Infection Control Plan were posted in a common area.

Food Service: Seven (7) days of non-perishable and three (3) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator present in the facility. LPA Beena Singh observed sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA Beena Singh reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. The files were complete with updated physician’s reports, admissions agreements, and pre-admissions appraisals. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings.

Medications/MARs records were audited and appeared to be dispensed appropriately by staff members.

An exit interview was conducted where this report was discussed and provided to Licensee/Administrator Heldo Taguba.

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

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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