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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800111
Report Date: 09/14/2023
Date Signed: 09/14/2023 01:00:38 PM

Document Has Been Signed on 09/14/2023 01:00 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
, CA 92507
FACILITY NAME:LAS PALMAS ADULT RESIDENCEFACILITY NUMBER:
361800111
ADMINISTRATOR:UMALI, TERESITAFACILITY TYPE:
735
ADDRESS:7217 LAS PALMAS DRIVETELEPHONE:
(909) 463-4028
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 4DATE:
09/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Neil Consuelo - AdministratorTIME COMPLETED:
01:05 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) Anna Bueno made an announced visit to the facility to conduct a required annual inspection. LPA met with DSP Danilo Millan who identified herself to staff and was advised of the purpose of the visit, who phoned Licensee of LPA's arrival. Licensee arrived shortly and administrator Neil Consuelo arrived during the visit. The facility is currently licensed as an Adult Residential Facility, vendored by the Inland Regional Center. The facility has capacity of four ambulatory clients. There were no clients present during today's visit.

LPA Bueno, DSP Millan, and Licensee Umali toured the interior and exterior of the facility. The facility has no bodies of water. There is a shaded patio area for clients. LPA, DSP, and Licensee observed that side gates were unlocked and free of obstruction. The facility had a working telephone for client use. The facility fire extinguisher was last inspected on 07/30/23. DSP tested smoke alarms and carbon monoxide detectors and LPA, DSP, and Licensee found all units to be in working order. A locked centralized cabinet is utilized for medications while client files are secured and locked in a standing closet. Sharps, toxins, and cleaning agents are kept locked and secured.

The following were observed of the physical plant:
Client Bedrooms and Bathroom: LPA, DSP, and Licensee observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. The facility had a supply of additional linens. LPA, DSP, and Licensee observed bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients. The facility keeps a supply of hygiene provisions.
Kitchen and Dining Areas: LPA, DSP, and Licensee inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. The facility menu is available for review. LPA and Licensee observed two (2) days supply of perishable food items and seven (7) days supply of nonperishable food items. The facility menu was available for review. The floors, and appliances were free from debris.
Common (living/activity) areas: LPA, DSP, and Licensee observed night adequate seating in the common areas. The facility had a supply of activities for the clients. LPA also reviewed updated employee report, and LIC 610E, emergency disaster plan.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: LAS PALMAS ADULT RESIDENCE
FACILITY NUMBER: 361800111
VISIT DATE: 09/14/2023
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 following records were inspected:
Client Records: LPA inspected four of four client files and found that it had the required documentation including an admissions agreement, physician's report, and Individual Program Plan (IPP).
Staff Records: LPA reviewed four of four staff files and found current first aid certifications and training verifications. The administrator certificates are current.

No deficiencies were issued during today's visit. An exit interview was conducted where this report was discussed and a copy was provided to administrator Consuelo at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2