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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411959
Report Date: 03/17/2023
Date Signed: 03/17/2023 10:33:09 AM


Document Has Been Signed on 03/17/2023 10:33 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:AMBERHILL GUEST HOMEFACILITY NUMBER:
336411959
ADMINISTRATOR:MARIA C.G. VICTORIOFACILITY TYPE:
740
ADDRESS:12729 AMBERHILL AVETELEPHONE:
(909) 923-2110
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 0DATE:
03/17/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Julita Rodriguez- AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Victoria Chitgian made an announced visit to conduct a Required Annual inspection. LPA met with Administrator Julita Rodriguez at the facility. This Residential Care Facility for the Elderly is licensed for six (6) residents.
LPA observed that there are currently no residents admitted to the facility. Administrator stated the facility intends to continue to be licensed. LPA toured the facility inside and out. There are no pools, bodies of water, firearms or ammunition. LPA observed the facility is kept at a comfortable temperature. Hot water was measured in the kitchen sink at 121 degrees Fahrenheit. LPA did not observe non-skid mats or strips in showers and tubs. The resident bedrooms did not have all the required furniture of chairs and dresser drawers. Technical Assistance provided. LPA observed a sufficient supply of towels, linens and personal hygiene items. Cleaning supplies were observed to be locked in the laundry room. The facility’s smoke detectors and carbon monoxide detectors were tested and are in working condition. Activity area has puzzles and a Television for resident engagement.
LPA observed the kitchen to be clean and free of odor and all food is stored in a healthful manner. Appliances were observed to be operating. Frozen and refrigerated food is sealed correctly and protected against contamination. LPA observed appropriate supply of seven (7) day non-perishable food in a pantry.
LPA observed where the resident’s medications would be centrally located. Medication cabinet is observed to be secured and locked with a code. The facility plans to have an appropriate number of staff present the during operating hours and during the evening/sleeping hours when admitting residents in care. LPA reviewed facility files, signs, and required forms. The facility did not have the Emergency Plan posted as required. The facility has a first aid kit available. The patio area is shaded and has tables and chairs for resident’s comfort. The back yard is completely enclosed and revealed no immediate hazards or obstructions.
No deficiencies issued during todays visit. Four (4) Technical Assistance notes provided seen on LIC 9102. An exit interview was conducted at the end of the visit where this report was provided to Administrator Julita Rodriguez.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Victoria ChitgianTELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023
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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