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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425336
Report Date: 03/22/2024
Date Signed: 03/22/2024 10:42:50 AM

Document Has Been Signed on 03/22/2024 10:42 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:ECO GREEN HOMEFACILITY NUMBER:
336425336
ADMINISTRATOR:RODRIGUEZ, AUDRAFACILITY TYPE:
735
ADDRESS:11052 CERES WAYTELEPHONE:
(951) 681-1121
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY: 4CENSUS: 2DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee/Administrator Audra RodriguezTIME COMPLETED:
10:45 AM
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On 03/22/2024 at 08:30 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there was two (2) staff present, and two (2) clients present. LPA Brown explained the purpose of the visit to Licensee/Administrator Audra Rodriguez.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, medication audit and P&I audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed two (2) clients. There are no obstructions to indoor and outdoor passageway of the facility. The facility is maintained at a comfortable temperature. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, storage space, night stand, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 116 degrees Fahrenheit. The facility is equipped with combined operational smoke detectors and carbon monoxide detectors, charged two (2) fire extinguisher, and first aid kit with first aid book. Posters such as the personal rights, CCLD complaint poster, emergency disaster plan were posted in a common area. Medications were kept in secure cabinets inaccessible to clients. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

*** Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ECO GREEN HOME
FACILITY NUMBER: 336425336
VISIT DATE: 03/22/2024
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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard. The outdoor pathway was free of obstructions. LPA Brown observed a pool inaccessible to clients, with the required fence and locked.

Food Service: LPA Brown observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA Brown reviewed two (2) client files for Admission Agreements, Needs and Services Plans, Functional Capabilities, and Physician Report (LIC602) and Individual Program Plan (IPP). LPA Brown observed that all files reviewed were complete. LPA Brown also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) Test result and Crisis Prevention and Intervention (CPI) Training. Per LPA Brown records review, files reviewed are complete. LPA Brown reviewed two (2) clients P&I records and LPA Brown observed no issue. LPA Brown audited two (2) clients medications, LPA Brown observed no issue.

No deficiencies or advisories were issued during this visit. An exit interview was conducted where this report LIC809 were discussed and copies were provided to Licensee/Administrator Audra Rodriguez.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
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