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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881202
Report Date: 11/03/2021
Date Signed: 11/03/2021 02:15:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DALIA'S BOARDING HOME INC.FACILITY NUMBER:
331881202
ADMINISTRATOR:FIGUEROA, FERNANDOFACILITY TYPE:
740
ADDRESS:4105 JACKSON ST.TELEPHONE:
(951) 743-7066
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 0DATE:
11/03/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Fernando Figueroa, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Tricia Danielson conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 1:00 PM, LPA met with Licensee/Administrator Fernando Figueroa. An initial application to operate a Residential Care For the Elderly (RCFE) facility was received by the Central Applications Unit (CAU) on 09/24/21 for a total capacity of six (6) residents, two (2) of which may be non-ambulatory. Fire Clearance was granted on 08/26/21 for six (6) residents, two (2) of which may be non-ambulatory. During today's visit, LPA Danielson observed the following:
Structure:
Facility was a single story house with four (4) resident bedrooms, two (2) resident bathrooms, living room, dining area and kitchen. There was an detached two (2) car garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each resident bedroom will accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm/carbon monoxide detector.
Bathrooms:
The two (2) resident bathrooms have a working toilet, wash basin and an adequate supply of paper towels, toilet paper, and soap. LPA verified bathroom water temperatures were measured at 120 and 120 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies were secured in the locked cabinet under the sink. Knives/sharp instruments were secured in a locked drawer.

(CONTINUED ON LIC 812C)
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DALIA'S BOARDING HOME INC.
FACILITY NUMBER: 331881202
VISIT DATE: 11/03/2021
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(CONTINUED FROM LIC 812)
There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all residents.
Living/Family room:
There was a living room with safe and adequate seating for all residents as well as working TV.
Linens and Hygiene Supplies:
An adequate supply of additional linens and medical supplies were stored in a hallway cabinets.
Yards/Outside:
There was a patio with adequate covered seating for all residents. All walkways were observed to be free of obstructions.
Garage:
Garage was free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Let-Us-No poster, emergency phone numbers, emergency exit plan, resident Personal Rights, and facility visitation policy were posted as required.
General items:
One (1) fire extinguishers was charged and located in the kitchen. Smoke alarms and carbon monoxide detectors were in working order. Resident records will be stored in a locked cabinet. First Aid kit with required components, and locked area for medication storage was observed. An emergency supply of water was observed stored in the garage and an emergency supply of food was observed in the kitchen pantry. LPA observed a facility phone and it was verified to be operational as evidenced by Administrator dialing the number to trigger a ring. Component III was completed during today's visit and a copy was also emailed to Licensee.

The following items must be corrected prior to the facility being issued a license:
The gate at the front of the house must be self latching. Administrator reported this item will corrected and proof will be forwarded to LPA.

An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC809 (FAS) - (06/04)
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