336402596-7-30-2023-18-AS-JROO-CU8PTN-20230730113614

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336402596
Report Date: 07/30/2023
Date Signed: 07/30/2023 11:36:20 AM

Document Has Been Signed on 07/30/2023 11:36 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SLB INCORPORATED-BAMBI		FACILITY NUMBER:	336402596
ADMINISTRATOR:	FORTAJADA, JAMIELAH		FACILITY TYPE:	735
ADDRESS:	13331 BAMBI COURT		TELEPHONE:	(951) 653-0604
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY: 6		CENSUS: 6	DATE:	07/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Administrator Michael Hall		TIME COMPLETED:	12:00 PM

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On 7/30/2023, at 10:45 a.m., Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Gina Elemento who was informed of the purpose of visit. CEO Michael A. Hall arrived during the visit. The facility is approved for 6 non-ambulatory clients. During the visit, there was six (6) clients and (3) staff present.

LPA toured the facility’s interior and exterior with Caregiver Elemento. During the visit, LPA observed the following:

Kitchen: LPA observed kitchen area to be clean. Food is stored in a safe and healthful manner. LPA observed the facility had a 2-day supply of perishable foods and 7-day of non-perishable food items. Knives/sharp instruments are secured in a locked kitchen cabinet under the sink.
Dining and Living room: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. LPA observed clients sitting in the living room watching television and sleeping. Home temperature was set to 76 degrees Fahrenheit.

Hallway: LPA observed hallway to be clean with no pathway obstruction. Facility has a fire alarm system, carbon monoxide & smoke detectors.

Continued on LIC809-C.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2023

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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SLB INCORPORATED-BAMBI	FACILITY NUMBER: 336402596
	VISIT DATE: 07/30/2023

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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a cabinet stored in the dining room. LPA reviewed physical medications for Client #1 as well as Medication Administration Record, no discrepancies discovered.

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathrooms has a working toilet, wash basin, and were equipped with a grab bar in the shower. The hot water temperature measured at 105- and 111-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the clients in care.

Laundry/Garage: LPA toured the laundry room and garage. Washing machine and dryer are in good repair. Cleaning solutions and chemicals are secured in locked laundry room. Emergency food supplies, water and incontinent supplies are stored in the garage.

Records: Staff present have a criminal record clearance on file and are associated to the facility. Staff training is up to date.

Yard/Outside Area: Shaded seating area is available for the clients to sit and relax. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

During today’s visit, LPA did not observe any deficiencies. An exit interview was conducted, and a copy of this report was reviewed and provided to CEO Hall.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2023

LIC809 (FAS) - (06/04)

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