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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408124
Report Date: 09/05/2024
Date Signed: 09/05/2024 01:44:32 PM

Document Has Been Signed on 09/05/2024 01:44 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SHELLEY'S HOUSEFACILITY NUMBER:
336408124
ADMINISTRATOR/
DIRECTOR:		AILEEN L. LOPEZFACILITY TYPE:
735
ADDRESS:186 EAST STREETTELEPHONE:
(951) 520-1073
CITY:NORCOSTATE: CAZIP CODE:
92860
CAPACITY: 4CENSUS: 3DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:11 PM
MET WITH:Marissa Olizeros.TIME VISIT/
INSPECTION COMPLETED:
02:00 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 Analysts (LPAs) Raquel Hernandez and Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs were granted entry to the facility and met with House Manager Marissa Olizeros. The facility is a six (6) bedroom, two (2), bathroom home and, with a kitchen/dining area, living room and attached garage. The facility is an Adult Residential Facility (ARF) level 4 designated home vendor by Inland Regional Center. Licensed capacity is (4). Current census (3). LPA was accompanied to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. All sharps are locked. There was a designated space for client/staff files. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.Record Review: LPAs reviewed (3) client files for admission agreements, updated physician reports, and needs and services plans. LPAs reviewed (2) client medications. LPAs observed no client response for Client#1 (C1) in MAR for PRN medication but was documented in the behavior notes for client. Technical Assistance was issued. LPA review (3) P&I and no issues were observed. LPA also reviewed (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) (LIC9102) was discussed and provide to House Manager Marissa Olizeros

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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