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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880918
Report Date: 09/04/2024
Date Signed: 09/04/2024 11:31:19 AM

Document Has Been Signed on 09/04/2024 11:31 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:LUPINE GARDENS CORONAFACILITY NUMBER:
331880918
ADMINISTRATOR/
DIRECTOR:		LEE, JACQUELINEFACILITY TYPE:
735
ADDRESS:19235 BOX CANYON RD.TELEPHONE:
(562) 284-9510
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 4CENSUS: 0DATE:
09/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Licensee/Administrator Jacqueline Lee TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 09/04/2024 at 9:02am, Licensing Program Analysts (LPAs) Raquel Hernandez and Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs met with Licensee/Administrator Jacqueline Lee and Licensee Joshua Lee and was granted entry to the facility. At the time of the visit there was two (2) staff present, and zero (0) clients present. The facility is a five (5) bedroom, three (3), bathroom home, with a kitchen/dining area, living room, and detached garage. The facility is an Adult Residential Facility (ARF) home and recently vendorized by Inland Regional Center (IRC) on 08/20/2024. Licensed capacity is (4), of which two (2) can be non-ambulatory and (2) two can be ambulatory. Current census is zero (0). LPAs were accompanied by Facility Licensee/Administrator Jacqueline Lee to conduct a general overall inspection, which included, but was not limited to, the following:
Physical Plant: The facility currently has no clients in care. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees. LPAs Hernandez and Brown inspected future client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. LPAs measured and observed the water temperatures in the bathrooms to be at 107 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 Emergency Disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible. There was a designated storage space for client/staff files. LPAs Hernandez and Brown observed empty medication closet where medication will be potentially stored and inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions.
Food Service: LPAs Hernandez and Brown observed seven (7) days non-perishable and two (2) days perishable food supply. Facility has a variety of food available. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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: LUPINE GARDENS CORONA
FACILITY NUMBER: 331880918
VISIT DATE: 09/04/2024
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*** Continuation from LIC809 ***
Care & Supervision: Facility currently has no clients in care. Administrator at the facility have criminal record clearance through the department.

Record Review: LPAs Hernandez and Brown observed Licensee/Administrator Jacqueline Lee Administrator Certification. LPA Hernandez and Brown viewed two (2) staff files for First Aid/CPR certification, criminal record clearance, and health screenings. LPAs Hernandez and Brown observed Licensee/Administrator Jacqueline Lee did not have a completed Tuberculosis (TB) test. Techinical violation was issued. Also, LPAs Hernandez and Brown observed Licensee/Administrator Jacqueline Lee did not have a completed health screening report. Technical violation will be issued. Medications were not audited as the facility currently has no clients.

Based on the observations made during today’s visit, techinical violations were issued per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809 and LIC9102 TV) was discussed and provided to Licensee/Administrator Jacqueline Lee.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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