<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360907981
Report Date: 08/16/2023
Date Signed: 08/16/2023 03:43:38 PM

Document Has Been Signed on 08/16/2023 03:43 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:SALEM CHRISTIAN HOME FOR THE HANDICAPPED INC.FACILITY NUMBER:
360907981
ADMINISTRATOR:ANGIE MILIUSFACILITY TYPE:
735
ADDRESS:12427 PALM PLACETELEPHONE:
(909) 248-0931
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 6CENSUS: 6DATE:
08/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Peter Pantoja - Lead StaffTIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required 1-year visit to the facility. LPA met with Peter Pantoja - Lead Staff and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), license capacity of (6) clients with a current census of (6). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPA inspected the facility inside and out. Indoor and outdoor passageways are kept free of obstruction. Facility has no bodies of water. Backyard is fenced with self-latching gates. Facility has sufficient outdoor and indoor space for clients activities. The facility has sufficient lighting and is maintained at a comfortable temperature.

LPA inspected the kitchen. Hot water temperature tested at 108 degrees F. Facility has sufficient non-perishable and perishable food for number of clients in care. Facility food is stored in a safe and healthful manner. Facility has sufficient cups, plates, and utensils for client use. Sharps, disinfectants, and chemicals are kept locked and inaccessible to clients in care.

LPA inspected client bedrooms. Bedrooms are equipped clean beds, linen, nightstands, chairs, dressers and sufficient lighting.

LPA inspected client bathrooms. Bathrooms are equipped with grab rails and operating in a safe and sanitary condition. Hot water temperatures tested between 108 and 112 degrees F.

LPA inspected client medications. Medications are labeled and administered as prescribed. Medications are kept locked and inaccessible to clients in care.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SALEM CHRISTIAN HOME FOR THE HANDICAPPED INC.
FACILITY NUMBER: 360907981
VISIT DATE: 08/16/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The facility is equipped with operating carbon monoxide alarms. Last emergency drill was conducted on 7/16/23. Facility has operating telephone service on the premises. Facility has posted in a common area facility sketch, personal rights, disaster plan and emergency numbers. Facility has a sufficient supply of linen, towels, hygiene products and emergency supplies, including bottled water and flashlights for clients in care.

LPA reviewed client files for admission agreements, Individual Program Plan (IPPs), physician reports and client safeguarded property records, all had the required documentation.

LPA reviewed staff files for criminal record clearances, first aid certifications, training, and health screenings, all had the required documentation.

An exit interview was conducted, where this report was discussed and a copy was provided to the Lead Staff at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2