360951409-2-10-2022-18-AS-BALN-CBHPYQ-20220210104418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 360951409
Report Date: 02/10/2022
Date Signed: 02/10/2022 10:44:25 AM

Document Has Been Signed on 02/10/2022 10:44 AM - 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:	GALONGO MICHAEL HOME		FACILITY NUMBER:	360951409
ADMINISTRATOR:	DANCY, BARBARA		FACILITY TYPE:	735
ADDRESS:	1452 W 5TH ST		TELEPHONE:	(909) 983-2957
CITY:	ONTARIO	STATE: CA	ZIP CODE:	91762
CAPACITY: 6		CENSUS: 3	DATE:	02/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Administrator Barbara Dancy		TIME COMPLETED:	10:55 AM

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Licensing Program Analyst (LPA)Bernadette Allen made an unannounced Required Annual visit to the above referenced facility. LPA was granted access to the home by Administrator Barbara Dancy. LPA informed Administrator of the purpose for today’s visit, was to inspect the facility to ensure the facility follows rules and regulations of California Code of Regulations. LPA conducted a general overall inspection, which included, but was not limited to, the following: physical plant; interior and exterior and records review.

Physical Plant: The home consists of (6) bedrooms, (4) restrooms, a living room, office, kitchen, dining area, garage, and backyard area. Per Barbara Dancy, no ammunition is kept in the home. Resident bedrooms were clean and were observed to have the required furniture, bed linens, proper lighting, drawer/closet space to accommodate each resident. A pool and spa were observed, and the gate was found to be locked.

LPA observed the schedule of planned client activities. The facility is stocked with a two-day supply of perishable and seven-day supply of nonperishable food items. Medications: are stored in a locked cabinet and administered according to the label instructions. Sufficient staff is employed and present in the facility to meet the needs of the consumers in care.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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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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
RIVERSIDE, CA 92507

FACILITY NAME: GALONGO MICHAEL HOME	FACILITY NUMBER: 360951409
	VISIT DATE: 02/10/2022

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All staff files that were reviewed have a criminal record clearance, as well as the first aid certificate available. Licensee has secured each consumer’s personal property and cash resources were balanced.

Smoke and carbon monoxide detectors were checked and were operable. Fire extinguishers were fully charged. LPA observed all knives were secured in a locked drawer located by the stove. The last fire drill and earthquake drill was conducted on 2/1/2022.

LPA measured the water temperature in the restrooms and found the water, to be within regulatory limits, measuring at approximately 102.2 degrees F. Resident bath towels and toiletries were adequately stocked. Common areas were clean, and all doorways were clear of obstructions inside the home. The kitchen was checked and observed to be within Title 22 regulations. LPA toured the backyard; the backyard was clean and clutter free. LPA found the side gate to be unlocked and accessible to residents.

Records Review: A disaster, mass casualty plan, and community care licensing complaint poster were observed to be posted at the facility. Resident records were current, and all had proper admission agreements.

No prohibited health conditions were observed. All staff records were current, and all training was up to date.

Based on this inspection, no deficiencies were observed at this time in the areas evaluated. An exit interview was conducted with the Administrator Barbara Dancy.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

LIC809 (FAS) - (06/04)

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