336408502-8-23-2024-56-AS-SRAZ-D8F26B-20240823170653

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336408502
Report Date: 08/23/2024
Date Signed: 08/23/2024 05:07:02 PM

Document Has Been Signed on 08/23/2024 05:07 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:	CASA MIA		FACILITY NUMBER:	336408502
ADMINISTRATOR:	LILIBETH SAMSON		FACILITY TYPE:	740
ADDRESS:	10650 54TH STREET		TELEPHONE:	(951) 685-9000
CITY:	MIRA LOMA	STATE: CA	ZIP CODE:	91752
CAPACITY:	20	CENSUS: 14	DATE:	08/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:58 PM
MET WITH:	Administrator Lilibeth Samson		TIME COMPLETED:	05:15 PM

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Licensing Program Analysts (LPAs) Sarina Ramirez and Magda Malcore made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs met with Administrator Lilibeth Samson and was granted entry to the facility. The facility is an (10) bedrooms, five (5) bathrooms home, with a kitchen/dining area, living room, and no garage. Licensed capacity is (20) current census (14). LPAs were accompanied by Administrator Samson 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 hot water temperature tested within regulation at 105 and 115 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, the disaster plan, emergency telephone numbers, ombudsman poster, and activities were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept locked inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. 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. All staff members working in the facility have criminal record clearance through the department.

*Continuation on LIC – 809-C*

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina Ramirez	TELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CASA MIA	FACILITY NUMBER: 336408502
	VISIT DATE: 08/23/2024

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Record Review: LPAs reviewed five (5) client files for admission agreements, updated physician reports, and needs and services plans. LPAs also reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I funds were counted and matched with the ledger. Medications were audited and appeared to be dispensed appropriately by staff members.

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) was discussed and provided to Administrator Lilibeth Samson.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina Ramirez	TELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC809 (FAS) - (06/04)

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