336425049-4-24-2025-56-AS-BSIH-DG2PNA-20250424112735

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425049
Report Date: 03/19/2025
Date Signed: 04/24/2025 11:28:08 AM

Document Has Been Signed on 04/24/2025 11:28 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ALICIA PINES RESIDENTIAL CARE		FACILITY NUMBER:	336425049
ADMINISTRATOR/ DIRECTOR:	OFELIA HOUSE		FACILITY TYPE:	740
ADDRESS:	6675 VALLEY DRIVE		TELEPHONE:	(951) 353-8900
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92505
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	03/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Facility-Licensee/Administrator Ofelia House		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

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On 03/19/2025 at 9:05 AM, Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Singh met with a staff Care giver Ellamae Santos and was granted entry to the facility. At the time of the visit there was one (1) staff present, and three (3) residents present. Licensee/Administrator Ofelia House arrived during the visit, LPA Singh explained the purpose of the visit to Licensee/Administrator House.

The facility is a six (6) bedroom, two (2) bathroom home with a kitchen/dining area, living room, laundry room and detached garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which (6) can be non-ambulatory residents and one (1) may be bedridden resident. The facility has three (3) Hospice Waiver. The current census is three (3) residents. LPA Singh was accompanied by Licensee/Administrator House (S1) 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 Division (CCLD). LPA Singh observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA Singh inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night-stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Singh observed grab bars and non-skid mat in the resident shared bathroom.

LPA Singh observed sufficient furniture and lighting throughout the facility. LPA Singh measured and observed the water temperatures in the bathroom to be at 110 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarm. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster and the disaster plan were posted in a common area. No smoking-oxygen in use signs have been posted in the appropriate areas.

***Continuation in LIC809C ***

Efren Malagon	TELEPHONE: (951) 202-6356
Beena Singh	TELEPHONE: (951) 248-2222
	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

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: ALICIA PINES RESIDENTIAL CARE	FACILITY NUMBER: 336425049
	VISIT DATE: 03/19/2025

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There is a steel cabinet with the resident’s medications locked in the activity area/office area. First Aid kit and first Aid book were observed at the facility.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator present in the facility. Enough staff to cover the day and night shift. LPA Singh observed staff scheduled to work at night (NOC) shift and the facility have two (2) dementia residents.

Record Review: LPA Singh reviewed three (3) resident files for admission agreements, updated physician reports, and resident appraisals. LPA reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings with Tuberculosis (TB) test result. LPA observed staff files reviewed were complete. Medications were audited for two residents and LPA Singh observed no issues. Licensee/Administrator House emailed the facility's Updated liability insurance effective date 3/8/2025 to LPA Singh.

Based on interviews and observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report LIC 809, LIC809 C were discussed and a copy of this report was provided to Licensee/Administrator Ofelia House at the conclusion of the inspection.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Beena Singh	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC809 (FAS) - (06/04)

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