<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402223
Report Date: 08/22/2024
Date Signed: 08/22/2024 06:05:33 PM

Document Has Been Signed on 08/22/2024 06:05 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AMY'S HOUSEFACILITY NUMBER:
336402223
ADMINISTRATOR/
DIRECTOR:		AILEEN ADAMSFACILITY TYPE:
735
ADDRESS:3731 CALIFORNIA AVETELEPHONE:
(951) 372-0554
CITY:NORCOSTATE: CAZIP CODE:
91760
CAPACITY: 4CENSUS: 4DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:57 AM
MET WITH:Administrator Tiffany CanlasTIME VISIT/
INSPECTION COMPLETED:
02:15 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) Sarina Ramirez conducted an unannounced required annual inspection to the facility. LPA met with Administrator Tiffany Canlas and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), level 4i. The facility is an Inland Regional Center (IRC) certified vendor with a license capacity of (6) and a current census of (4). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant & Operation: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Facility's backyard is enclosed and gated. Indoor and outdoor activity areas are sufficient for clients in care. Client activities include community outings and day program participation. The facility has sufficient lighting and is maintained at a comfortable temperature. Client bathrooms were operating in sanitary conditions. The hot water temperature measured at 109 and 106 degrees F. Client bedrooms have sufficient lighting and furniture in good repair. Facility has operating smoke detector and carbon monoxide alarms, laundry equipment and telephone service. The facility has sufficient linens and personal hygiene items for clients in care. The facility has posted in a common area disaster evacuation plan, complaint poster, facility license, house rules, personal rights, activity schedule, and facility staff schedule.


Food Service: The facility has sufficient non-perishable and perishable food supply for clients in care. Sharps and chemicals were kept locked in kitchen area.
**** Continuation on LIC 809 – C****
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AMY'S HOUSE
FACILITY NUMBER: 336402223
VISIT DATE: 08/22/2024
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
Care & Supervision: Facility has 24 hour care staff. Staff working have criminal record clearances.

Record Review: Review of (4) Client files were observed to be complete. Review of (4) staff files were observed to be complete.

Medical Related Services: Client’s medications are labeled and centrally stored in a locked cabinet.

Based on observations and record review, no deficiencies were cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where the Licensing report were discussed and copies of the report were provided to Administrator Tiffany Canlas.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2