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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360910971
Report Date: 06/23/2023
Date Signed: 06/23/2023 02:30:16 PM

Document Has Been Signed on 06/23/2023 02:30 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:PLEASANT BOARD AND CAREFACILITY NUMBER:
360910971
ADMINISTRATOR:HAROLD DE JESUSFACILITY TYPE:
735
ADDRESS:1559 SO. PLEASANT AVE.TELEPHONE:
(909) 984-8594
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 6CENSUS: 4DATE:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Harold De Jesus - AdministratorTIME COMPLETED:
02:45 PM
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 Licensing Program Analyst (LPA) Victoria Chitgian arrived unannounced to conduct a visit to the facility for a required annual inspection. Facility is an Adult Residential Facility licensed for one (1) ambulatory and five (5) non-ambulatory clients. LPA met with Administrator Harold De Jesus at the facility.
LPA conducted a walk-through the facility's interior and exterior. The facility has a charged fire extinguisher, operating fire alarm systems, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review and included nutritious options. LPA toured the client bedrooms. The client bedrooms had functional lighting and required furniture. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last fire/disaster drill was conducted on 6/3/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. LPA toured the bathrooms and kitchen. Hot water temperature was measured in the bathrooms and kitchen and was found within required limits at 107 degrees Fahrenheit. LPA observed emergency supplies in the hallway closet. The outside of the facility had a shaded area with seating for client comfort. The facility does not have bodies of water.
LPA reviewed staff and client files. During Staff file review, LPA did not observe the required Administrator HIV/TB training course. Technical violation issued. Administrator agreed to enroll and complete the course. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans with the exception of Client 1; 80068(a)(1) Objection of placement was not indicated as required. Technical violation issued. Administrator will coordinate with the Inland Regional Center Service coordinator to complete the requirement. LPA inspected client medications. Medications were dispensed appropriately according to the physician's orders. Licensee has secured each consumer’s personal property and cash resources. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PLEASANT BOARD AND CARE
FACILITY NUMBER: 360910971
VISIT DATE: 06/23/2023
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LPA observed signs and postings in a common area in the dining room. LPA did not observe a policy on visitation. Administrator agreed to display the policy on visitation. Technical violation issued.

No deficiencies were cited during this visit. Three (3) technical violations issued. An exit interview was conducted where this report LIC 809, and LIC 9102 was discussed and provided to the Administrator Harold De Jesus, at the end of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
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