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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530034
Report Date: 11/04/2022
Date Signed: 11/04/2022 03:29:18 PM


Document Has Been Signed on 11/04/2022 03:29 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:EARLY BIRD CARE HOMEFACILITY NUMBER:
335530034
ADMINISTRATOR:CHANSARASETH, PATSARAFACILITY TYPE:
740
ADDRESS:6547 PERIDOT CTTELEPHONE:
(657) 722-9269
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 0DATE:
11/04/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Patsara ChantharasethTIME COMPLETED:
03:40 PM
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Licensing Program Analysts (LPA’s) Victoria Chitgian and Natalie Ibarra conducted an announced pre-licensing visit to the facility. LPA’s met with Licensee Patsara Chantharaseth. The pending application is for a Residential Care Facility for the Elderly (RCFE). Currently there are zero (0) residents in care. Licensee accompanied LPA’s on a tour of the inside and outside of the facility. The home is a two (2) story eight (8) bedroom three (3) bathroom home with a living room, dining room, and kitchen. Upstairs area will be used as office space, storage and staff rooms. The physical plant, in general, was in good repair. Buildings and grounds are free from hazards. Indoor and outdoor passageways are free of obstruction. There are no pools, bodies of water, firearms or ammunition. All bedrooms are furnished with a bed, nightstand, dresser and chair. All bedrooms have adequate lighting for resident use. Bathroom’s toilet, shower and tubs are in good repair and have non-skid mats. LPA’s measured and observed the water temperature in the bathrooms to be at 107.2 degrees F. LPAs observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer are maintained at appropriate temperature. All appliances are clean and operating properly. Dishes, glasses, and utensils were in good condition. There is sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present. The backyard is completely enclosed with functioning gate to exit to the front yard. Outdoor space is suitable for resident use. LPA’s observed full charged fire extinguisher present at the facility. Smoke alarms, carbon monoxide are present and functional. Medications are to be stored and secured in a locked closet in the kitchen and inaccessible to residents. The facility has a designated area for staff and residents’ records. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There is adequate seating in the common areas. Facility has a supply of activities for residents.

Pre-licensing inspection is complete, and no corrections are needed to be made.
An exit interview was conducted, and a copy of this report was provided to the licensee.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Victoria ChitgianTELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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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