331881214-2-29-2024-56-AS-JPRO-D2VRE3-20240228115651

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881214
Report Date: 02/28/2024
Date Signed: 02/29/2024 08:35:19 AM

Document Has Been Signed on 02/29/2024 08:35 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	BELLES COURT		FACILITY NUMBER:	331881214
ADMINISTRATOR:	ANCHONDO, JESSICA		FACILITY TYPE:	735
ADDRESS:	6770 CONDOR DR		TELEPHONE:	(323) 945-5605
CITY:	JURUPA VALLEY	STATE: CA	ZIP CODE:	92509
CAPACITY: 4		CENSUS: 3	DATE:	02/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Nidia Ruiz, Administrator		TIME COMPLETED:	12:15 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Facility Administrator Nidia Ruiz and was granted entry to the facility. At the time of the visit there was two (2) staff present, and one (1) client present.

The facility is a four (4) bedroom, two (2) bathroom home, with a kitchen/dining area, living room, and attached garage. The facility is an Adult Residential Facility (ARF) level 4I designated home vendorized by Inland Regional Center. Licensed capacity is (4) current census (4). LPA was accompanied by Facility Administrator Ruiz 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). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client 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 observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 126 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 were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. ***continued on LIC 809C***

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: BELLES COURT	FACILITY NUMBER: 331881214
	VISIT DATE: 02/28/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

There was a designated storage space for client/staff files. Medications are kept inside medication closet inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. The last fire drill was conducted on 02/05/2024. The last Earthquake drill was conducted on 12/03/2023.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed four (4) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I fund were counted and matched with the ledger. Medications were audited at random and appeared to be dispensed appropriately by staff members.

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

An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Ruiz.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2