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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530048
Report Date: 02/15/2024
Date Signed: 02/15/2024 01:54:57 PM

Document Has Been Signed on 02/15/2024 01:54 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:EMMA'S CASE ARF INC.FACILITY NUMBER:
335530048
ADMINISTRATOR:CHAVEZ, ALIX GARCIAFACILITY TYPE:
735
ADDRESS:20043 CASE STTELEPHONE:
(909) 316-9555
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 4CENSUS: 0DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Alix Garcia Chavez- AdministratorTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Alix Garcia Chavez and was granted entry to the facility.
The facility is an Adult Residential Facility (ARF) licensed for a capacity of two (2) ambulatory clients and two (2) non- ambulatory clients. The facility is level 4i vendorized by Inland Regional Center (IRC). The current census is zero (0) clients. The facility is waiting on client placement from IRC. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following:

There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected 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. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathrooms to be at 110.3 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to future clients in care. There is a designated storage space for future client files and future staff files. Medications will be kept inside a locked closet near the kitchen inaccessible to future clients.

The facility does not have any client records to review. LPA reviewed one (1) staff file for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings.

Based on the observations made during today’s visit, no 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 Administrator Alix Garcia Chavez.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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