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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360910971
Report Date: 02/17/2022
Date Signed: 02/17/2022 12:42:18 PM


Document Has Been Signed on 02/17/2022 12:42 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
RIVERSIDE, CA 92507



FACILITY NAME:PLEASANT BOARD AND CAREFACILITY NUMBER:
360910971
ADMINISTRATOR:LIGAYA P. DE JESUSFACILITY TYPE:
735
ADDRESS:1559 SO. PLEASANT AVE.TELEPHONE:
(909) 984-8594
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY:6CENSUS: 4DATE:
02/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Harold De JesusTIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPAs) Anna Bueno and Ryan Gardner conducted an unannounced visit to the facility for a case management visit. LPAs met with administrator Harold De Jesus.

On December 20,2021, the Licensee submitted a requested a reduction in capacity, a change of ambulatory/non-ambulatory status, and a waiver request for two (2) non-ambulatory residents. The facility is currently licensed for six (6) clients, five (5) of which are non-ambulatory with gastronomy feeding, hydration, and care. A representative from the Fire Department conducted a fire safety inspection on 2/7/2022 and approved for the change in ambulatory status with corrections.

During today’s visit, LPAs toured the facility inside and out and observed that door jambs and walls have been marked for the needed corrections. LPAs advised Administrator to provide construction details such as, Ontario Fire Department deadline for corrections, construction schedule, construction start and end dates. Once the construction and Fire Inspection are completed, the Licensee will contact LPA for another inspection before a new license will be issued.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the Administrator.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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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