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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412327
Report Date: 05/05/2023
Date Signed: 05/05/2023 02:34:48 PM

Document Has Been Signed on 05/05/2023 02:34 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:CARE LOVE HOMEFACILITY NUMBER:
336412327
ADMINISTRATOR:ROSARIO MANIQUISFACILITY TYPE:
735
ADDRESS:13691 DELLBROOK STREETTELEPHONE:
(909) 923-5159
CITY:CORONA,STATE: CAZIP CODE:
92880
CAPACITY: 6CENSUS: 4DATE:
05/05/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Licensee Rosario ManiquisTIME COMPLETED:
03:00 PM
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 Licensing Program Analyst (LPA) Victoria Chitgian arrived unannounced to the facility for a Required Annual inspection. Facility is an Adult Residential Facility licensed for four (4) ambulatory clients. LPA met with Administrator Rosario Maniquis. At the time of the visit, all clients were out of the facility at Day program.
LPA toured the facility inside and outside. Outdoor and indoor passageways were kept free of obstruction. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. LPA toured the client bedrooms. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 4/26/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Cleaning supplies were stored in the storage and laundry areas. Centrally stored medications were kept in a safe and locked closet. LPA toured the client bathrooms. LPA measured the hot water temperature in the bathroom which measured 121 degrees Fahrenheit. LPA observed emergency supplies in the hallway closet. The outside of the facility had a shaded area with a table and chairs. The facility does not have a pool or bodies of water.
LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification including the Administrators HIV/TB training. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. Facility has secured each consumer’s personal property and cash resources. All required signs and postings were visible in a common area with the exception of the facility Visitation Policy. Administrator stated it is incorporated in the facility plan, and will post it in a public area. Deficiency issued. LPA observed the LIC 610D was outdated, from 2015. Per Administrator, there are no changes to the plan. Technical Assistance provided. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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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: CARE LOVE HOME
FACILITY NUMBER: 336412327
VISIT DATE: 05/05/2023
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One(1) deficiency was issued during this visit. One Technical Assistance for the LIC 610D. An exit interview was conducted where this report, LIC-809-D was discussed and provided to the Administrator Rosario, at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/05/2023 02:34 PM - It Cannot Be Edited


Created By: Victoria Chitgian On 05/05/2023 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CARE LOVE HOME
FACILITY NUMBER: 336412327

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(e)
(e)The information specified … including the visiting policy as stated in the admissions agreement shall be prominently posted in areas accessible to clients and their visitors.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the facility did not comply with the section cited above by not displaying the facility policy on Visitation, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2023
Plan of Correction
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Adminsitrator will develop and post the policy on Visitation and submit proof to the LPA via photo/email by the POC due date above.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
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