331881202-11-25-2024-18-AS-AZEO-DBCSAE-20241125124213

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881202
Report Date: 11/25/2024
Date Signed: 11/25/2024 12:42:25 PM

Document Has Been Signed on 11/25/2024 12:42 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	DALIA'S BOARDING HOME INC.		FACILITY NUMBER:	331881202
ADMINISTRATOR/ DIRECTOR:	KEN CLAVIO		FACILITY TYPE:	740
ADDRESS:	4105 JACKSON ST.		TELEPHONE:	(951) 743-7066
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS:	DATE:	11/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:05 AM
MET WITH:	Maribel Sacaros		TIME VISIT/ INSPECTION COMPLETED:	12:50 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Abdoulaye Zerbo, and Armando Perz conducted an unannounced visit for a required annual inspection. The LPAs were greeted by the caregiver Maribel Sacaros, notified her of the purpose for the visit and were allowed to enter the facility to conduct the inspection.

Facility Overview: The facility is a single story building with 4 residents bedrooms, 2 bathrooms, a detached garage. There is no gated pool and there are no firearms on the premises.

Infection Control: LPAs observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in a kitchen cabinet and inaccessible to residents. The smoke detector and carbon monoxide detector were operational. LPAs observed fire extinguishers not to be in compliance with the department requirements and with an expiration date of 06/29/2024. A citation will be issued. LPAs observed the hot water temperature to meet requirements at 117.5°F.

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.

Continued on LIC809-C.....

Rikesha Stamps	TELEPHONE: (951) 212-0616
Abdoulaye Zerbo	TELEPHONE: (951) 248-2222
	DATE: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DALIA'S BOARDING HOME INC.	FACILITY NUMBER: 331881202
	VISIT DATE: 11/25/2024

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Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of June 29th, 2026 and a CPR certification with the expiration date of 10-31-25

Record Review and Resident/Staff Files: LPAs reviewed files for four(4) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. LPAs observed none of the staff were associated to the facility including the administrator. A citation will be issued. Four(4) residents' files were reviewed and contained all required documentation. LPAs observed Staff and resident files to be stored in a locked cabinet in the dining area. The first aid kit was stored in a cabinet in the living room.

Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet in the hallway. LPAs reviewed medications for four residents, confirming that all medications were listed and accounted for.

Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 11-04-2024, which met department requirements. All facility exits were clear of obstructions.

Two deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Licensee Fernando Figuroa along with the appeal rights..

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Abdoulaye Zerbo	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/25/2024 12:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DALIA'S BOARDING HOME INC.	FACILITY NUMBER: 331881202
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87203 All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in one(1) out of (1) fire extinguisher not service yearly as required. The last yearly service was completed on 6-29-25,which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/26/2024
	Plan of Correction
1 2 3 4	Licensee will service the fire extinguisher and send picture to LPA by POC due date

Section Cited

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,interview, record review, the licensee did not comply with the section cited above in 1 out of 1 guardian roster not to have association of the current staff working at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2024
	Plan of Correction
1 2 3 4	Licensee will associate all staff members to the facility and will let LPA know for verificatino by POC due date

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Rikesha Stamps	TELEPHONE: (951) 212-0616
Abdoulaye Zerbo	TELEPHONE: (951) 248-2222
	DATE: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC809 (FAS) - (06/04)

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