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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402597
Report Date: 02/26/2024
Date Signed: 02/26/2024 11:46:30 AM

Document Has Been Signed on 02/26/2024 11:46 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SLB INCORPORATED-OLD VALLEYFACILITY NUMBER:
336402597
ADMINISTRATOR:FORTAJADA, JAMIELAHFACILITY TYPE:
735
ADDRESS:23484 OLD VALLEY DRIVETELEPHONE:
(951) 243-9746
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 5DATE:
02/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jamielah Fortajada - AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator Jamielah Fortajada and informed her of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include: soap and paper towels at hand washing stations, hand washing guides posted, and monitoring the residents and staff for symptoms of infectious diseases.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin observed the facility to be a comfortable temperature and that the hot water in the bathroom faucets measured at 120 degrees. LPA Colvin observed the bathroom sink to have a slow drain while measuring the hot water temperature. Since the water did still drain after a short period, LPA Colvin is only issuing a Technical Assistance (TA) Advisory Note and recommending that the facility look into correcting the slow drain. LPA Colvin did not observe any obstructions to emergency exits or hallways/walkways. LPA Colvin observed staff testing the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives and dangerous chemicals were locked in a cabinet in the kitchen, away from residents' reach.

Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 4 non-ambulatory and 2 ambulatory residents.

Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that there is a certified Administrator present.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SLB INCORPORATED-OLD VALLEY
FACILITY NUMBER: 336402597
VISIT DATE: 02/26/2024
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Staffing & Staff Records (Continued): LPA Colvin confirmed staff have criminal record clearance and have training to perform their required duties. Staff present have current CPR/First Aid Certification and have other relevant training listed in their files. LPA Colvin interviewed staff during today's inspection and experienced difficulty understanding and answering some of the questions asked by LPA Colvin. Since this staff member (S1) is not the only staff present at the facility during their shift and LPA Colvin was able to successfully interview other staff members present, LPA Colvin does not have a concern at this time with this negatively affecting facility operations, though it is being noted in case there is an issue in the future.

Resident Records: LPA Colvin reviewed the files for all 5 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin was unable to interview any of the 5 residents at the facility, as 3 were out in the community, 1 was sleeping, and 1 was engaged in another activity. LPA Colvin reviewed medications and did not observe any concerns during today's inspection.

Food Services: LPA Colvin observed the facility to have the required amount of perishable and non-perishable food. LPA Colvin observed the kitchen and dining area to be maintained in a clean and healthful manner. Sufficient dishware and silverware was present for residents use.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet in the kitchen and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions, though they do retain one resident with a Restricted Health Condition and LPA Colvin confirmed that the facility has the required Care Plan for the resident and staff training on file.

Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file and conducts regular Emergency Disaster drills.

An exit interview was conducted with Administrator Jamielah Fortajada and a copy of this report and LIC9102 was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024
LIC809 (FAS) - (06/04)
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