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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423920
Report Date: 05/08/2024
Date Signed: 05/08/2024 01:17:41 PM

Document Has Been Signed on 05/08/2024 01:17 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SLB, INC-SIERRA BRAVOFACILITY NUMBER:
336423920
ADMINISTRATOR/
DIRECTOR:		BELUSO, LYDAFACILITY TYPE:
735
ADDRESS:25602 SIERRA BRAVO CT.TELEPHONE:
(951) 247-7585
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 6CENSUS: 6DATE:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Jeffrey Castillo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with caregiver Teresita Sumalde, who was informed of the purpose of the visit. Administrator Jeffrey Castillo arrived shortly after LPA's arrival. At the time of the visit there was two (2) staff and three (3) clients present. The clients served are non-ambulatory developmentally disabled adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were in good repair and were present. The outdoor area was observed to be free of hazards and contained a shaded seated area for clients. The sharp and dangerous objects were observed to be locked and inaccessible to clients located under the kitchen sink. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at 111 degrees which met department requirements. LPA observed PPE equipment, hand washing signs, and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements.



LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

LPA reviewed three staff files and training. All staff have personal records, criminal record clearance, health screening, and updated training. Three client files were reviewed, and possessed all required paperwork including Admissions Agreement, Annual Physician's Report, and current Individual Program Plan (IPP). LPA inspected the P&I for three clients and found no discrepancies.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SLB, INC-SIERRA BRAVO
FACILITY NUMBER: 336423920
VISIT DATE: 05/08/2024
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All client medication was centrally stored and locked in a cabinet located near the kitchen. LPA reviewed medications for three clients and found all medication listed on the Medication Administration Record (MAR) and all required labeling and signatures were found to be in place.

LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills was conducted on 04/13/2024, which met the department requirements. LPA observed emergency supplies and first aid kit with all required items. The facility has a charged fired extinguisher located in the facility. The facility does not contain any bodies of water on the property. There are no firearms or ammunition stored at the facility.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Administrator Castillo.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
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