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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911227
Report Date: 10/28/2022
Date Signed: 10/28/2022 12:52:01 PM

Document Has Been Signed on 10/28/2022 12:52 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:SHADY GLENFACILITY NUMBER:
360911227
ADMINISTRATOR:PENDINGFACILITY TYPE:
735
ADDRESS:2571 SHADY GLEN LANETELEPHONE:
(909) 783-8806
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92408
CAPACITY: 5CENSUS: DATE:
10/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Michael Brletich, AdministratorTIME COMPLETED:
01:00 PM
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LPA Amber Coleman, (LPA Coleman) and LPA Anna Bueno (LPA Bueno) made an unannounced visit to the Shady Glen Facility to conduct an annual inspection with a focus on Infection Control. LPAs met with the Michael Brletich, Administrator (Admin.) who invited LPAs inside. Where LPA's were asked to sign in and complete temperature checks. LPA's and Administrator made introductions and discussed the purpose of the visit. COVID station displayed efficient PPE, hand sanitizer, disinfectant and sign in sheets. The current census is 3 consumers. During the visit, consumers were in their prospective day programs.

Administrator walked LPA's through the facility. Infection control signage was posted throughout the facility The facility is two stories with 4 rooms, a den, living and dining rooms. The Living and Dining rooms were observed to have adequate furniture and seating arrangements for consumers. The kitchen was found to be orderly. LPA's observed the kitchen to have an adequate amount of perishable and non perishable food. The refrigerator displayed the food menu and activities calendar. Admin. also showed LPA's a well stocked emergency supply in both the kitchen and garage areas. The backyard provides adequate shaded seating for consumers. Fire extinguishers (2) were seen both upstairs and downstairs; last inspection dated June 17th, 2022. Fire and carbon monoxide alarms were tested during the visit and found to be in proper function. Medications were centrally stored and secured in the staff office along with the sharps, cleaning supplies and a first aid kit. Admin. also showed LPA's the garage where the additional emergency food and supplies are kept.

Upstairs 1 consumer occupies a room and 2 consumers share a room with an attached bathroom Each room was secure and stocked with clean linens and secure windows. Each of the two bathrooms were observed to have adequate soap, paper towels and wastebaskets.

Based on interviews and observations made during today’s inspection a technical advisory was issued due to staff not being N95 Fit Tested. An exit interview was conducted where this report was discussed and a copy of this report was provided to Michael Brletich at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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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