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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360900053
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:38:43 PM

Document Has Been Signed on 08/30/2023 04:38 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:BAKERS HOMEFACILITY NUMBER:
360900053
ADMINISTRATOR:BRADSHAW, JOHNFACILITY TYPE:
735
ADDRESS:16646 BASELINETELEPHONE:
(909) 823-5549
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: 6DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:John BradshawTIME COMPLETED:
04:42 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility to conduct a required annual inspection. LPA identified herself to staff Bertha Leialoha and Alexis Bradshaw who were advised of the purpose of the visit. Staff informed LPA that licensee and administrator John Bradshaw was in the office with Inland Regional Center (IRC) CSC for a quarterly visit for three clients.

The facility is currently licensed as an Adult Residential Facility, vendored by IRC. The facility has capacity of six ambulatory clients.

LPA Bueno and staff Bradshaw toured the facility. The facility has no bodies of water. There is a shaded front patio for clients. LPA observed side gate is unlocked and free of obstruction. The facility has a working telephone for use. The facility fire extinguishers were last inspected on 06/14/2023. Staff tested the smoke alarms and LP tested the carbon monoxide detector and all units were in working order. Staff and client files are secured in the office while medication are locked in cabinet. Sharps, toxins, and cleaning agents are kept locked.

The following were observed of the physical plant:
Client Bedrooms and Bathroom: LPA and staff observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. The facility had a supply of additional linens. LPA and staff observed bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients. The facility keeps a supply of hygiene provisions.
Kitchen and Dining Areas: LPA and staff inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. The facility menu is available for review. LPA and Licensee observed two (2) days supply of perishable food items and seven (7) days supply of nonperishable food items.
Common (living/activity) areas: LPA and staff observed adequate seating in the common areas. The facility had a supply of activities for the clients.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: BAKERS HOME
FACILITY NUMBER: 360900053
VISIT DATE: 08/30/2023
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The following records were inspected:
Client Records: LPA inspected six of six client files and found that it had the required documentation including an admissions agreement, and Individual Program Plan (IPP).
Staff Records: LPA reviewed three staff files and found current first aid certifications and training verifications.
Centralized Medication: LPA observed three client medications audited by IRC CSC.
LPA also reviewed fire and earthquake drill logs. Licensee verified that current personnel report is accurate and the emergency disaster plan will be updated. A copy will be sent to CCL at a later time.

No deficiencies were issued during today's visit. Technical violations are being issued for issues found during the visit that were immediately corrected and did not pose as health and safety concerns as clients were not present at the facility at the time the violations were found. An exit interview was conducted where this report was discussed and a copy was provided to Licensee John Bradshaw at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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