335530128-9-23-2024-56-AS-JPRO-D99SHB-20240919135316

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530128
Report Date: 09/19/2024
Date Signed: 09/23/2024 08:25:59 AM

Document Has Been Signed on 09/23/2024 08:25 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:	EARLY BIRD CARE HOME		FACILITY NUMBER:	335530128
ADMINISTRATOR:	CHANTHARASETH,PATSARA		FACILITY TYPE:	740
ADDRESS:	11860 CONFLUENCE DR		TELEPHONE:	(951) 268-6525
CITY:	JURUPA VALLEY	STATE: CA	ZIP CODE:	91752
CAPACITY:	6	CENSUS: 6	DATE:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Chantharaseth, Patsara Licensee		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Javier Prieto visited the facility unannounced to complete a comprehensive annual inspection. LPA Prieto met with Chantharaseth, Patsara Licensee explained the purpose of the visit. Today’s inspection included a facility tour, record review, and interviews with staff and residents.

The facility is five (5) bedrooms and three (3) bathrooms of which four (4) bedrooms are used for residents in care. The facility also has kitchen/dining area, living area, covered patio, and attached garage. Licensed capacity is six (6), and the facility is at maximum capacity.

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility temperature is 76 degrees Fahrenheit. LPA inspected resident bedrooms; each room included required furniture such as mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were functional. LPA Prieto observed adequate furniture and lighting throughout the facility. The hot water temperature tested at 117.0 degrees Fahrenheit. The facility has operating smoke detectors and carbon monoxide alarms, which LPA Prieto tested during the visit. LPA Prieto observed personal rights posters, Licensing documents, and the disaster plan posted throughout the facility. LPA Prieto observed that cleaning supplies, toxins, sharps, and other dangerous items are kept secure and inaccessible to residents in care. There was a designated storage space for client/staff files. LPA Prieto observed medications locked and inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

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

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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

FACILITY NAME: EARLY BIRD CARE HOME	FACILITY NUMBER: 335530128
	VISIT DATE: 09/19/2024

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Care & Supervision: The facility staff is sufficient in number for the care and supervision of residents in care. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA Prieto reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. Medications were audited randomly and appeared to be dispensed appropriately by staff members. LPA Prieto reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings.

No deficiencies were cited during today's visit. LPA Prieto conducted an exit interview with Chantharaseth , where a copy of this report was discussed and provided.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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