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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402613
Report Date: 12/30/2024
Date Signed: 12/30/2024 11:45:43 AM

Document Has Been Signed on 12/30/2024 11:45 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SACRED HEART HOME FOR ELDERLYFACILITY NUMBER:
336402613
ADMINISTRATOR/
DIRECTOR:
TAGUM, NELIA TOLEDOFACILITY TYPE:
740
ADDRESS:291 WEST DALE STREETTELEPHONE:
(951) 845-8978
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
12/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Nelia TagumTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Licensee Nelia Tagum and was granted entry to the facility. LPA discussed the purpose of the visit with the Licensee. The facility is a single level Residential Care Facility for Elderly (RCFE) with a license capacity of (6), and a current census of (2). LPA conducted a general inspection of facility, which included, but was not limited to, the following:

Operation/Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). The facility has an emergency/disaster plan and infection control plan for review. Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. The facility is maintained at a temperature of 74 degrees F and the facility's fireplace is maintained covered. The facility is equipped with operating smoke/carbon monoxide alarms, fully charged fire extinguishers, laundry equipment, and telephone service. The facility has posted in a common area Community Care Licensing complaint poster, Ombudsman poster, facility license, evacuation plan and emergency telephone numbers. Sharps and cleaning supplies were kept locked and inaccessible to residents in care. Five (5) resident bedrooms were furnished with beds, night stands, chairs, bed linen and operating lighting. Two (2) resident bathrooms were maintained clean and equipped with grab rails and non-slip mats. The hot water temperatures in the bathrooms measured at 105 degrees F. The facility has 24 hours a day care staff.

Food Service: Non-perishable and perishable food supply was sufficient for number of residents in care. The facility’s refrigerator and freezer were operating properly.

Health Related Services: Medications were centrally stored and kept in a locked cabinet.

Record Review: Two (2) resident files were reviewed for admissions agreements, physician’s reports, preplacement appraisals, needs and services plans. Two (2) staff files were reviewed for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings. The Licensee's Administrator's certification is current.

Karen ClemonsTELEPHONE: (951) 248-0349
Magda MalcoreTELEPHONE: 951-248-0316
DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SACRED HEART HOME FOR ELDERLY
FACILITY NUMBER: 336402613
VISIT DATE: 12/30/2024
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During today's visit, technical advisories were issued per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy provided to Licensee Tagum at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC809 (FAS) - (06/04)
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