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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411959
Report Date: 02/29/2024
Date Signed: 02/29/2024 11:44:44 AM


Document Has Been Signed on 02/29/2024 11:44 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:
02/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Julita Rodriguez- Facility ManagerTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Manager Julita Rodriguez and was granted entry to the facility.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents. The current census is zero (0) residents. LPA was accompanied by Facility Manager to conduct a general overall inspection, which included, but was not limited to, the following:



There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathrooms to be at 109.2 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. The postings such as the facility license, personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. The cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to future residents in care. There was a designated storage space for future resident files and staff files. The medications will be stored in a entry way closet inaccessible to future residents.

The facility does not have client files to review. LPA reviewed one (1) staff file 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) was discussed and provided to Facility Manager Julita Rodriguez

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
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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