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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800111
Report Date: 12/27/2023
Date Signed: 12/27/2023 11:01:52 AM

Document Has Been Signed on 12/27/2023 11:01 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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:
12/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Neil ConsueloTIME COMPLETED:
11:05 AM
NARRATIVE
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On 12/27/23, Licensing Program Analysts (LPAs) Melody Brown and Bianca Wolcott conducted an unannounced visit to the facility for the purpose of completing a Case Management Visit. LPAs Brown & Wolcott was greeted and granted entrance by a staff. LPA Brown & Wolcott met with Administrator Neil Consuleo and explained the purpose of today's visit. Administrator Consuelo accompanied LPAs Brown and Wolcott on a tour of the inside and outside of the facility.

One (1) client in care was present during visit. Other clients are out in the community. Client appeared to be safe with no imminent health/safety concerns observed. During the tour of the facility. LPAs Brown & Wolcott observed additional room on the second floor of the facility. Alteration was made to add additional room in the master's bedroom. Per documents review, LPAs Brown and Wolcott observed no permits submitted to Community Care Licensing Division (CCLD) and corresponding city government agency. Deficiency will be issued. Moreover, LPAs Brown and Wolcott measured the facility's hot water and LPAs Brown and Wolcott observed the water to be 151 degrees Fahrenheit. Deficiency will be issued. LPAs Brown and Wolcott inspected the facility's food supplies and observed two (2) day(s) supply of perishable and seven (7) day(s) supply of non-perishable food. LPAs Brown & Wolcott observed proper signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient inaccessible to clients in care.

An exit interview was conducted where this report (LIC 809), LIC809D and Appeal Rights were discussed and provided to Administrator Neil Consuelo.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023
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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Document Has Been Signed on 12/27/2023 11:01 AM - It Cannot Be Edited


Created By: Bianca Wolcott On 12/27/2023 at 10:28 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LAS PALMAS ADULT RESIDENCE
FACILITY NUMBER: 361800111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/29/2024
Section Cited
CCR
80086(a)

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80086 Alterations to Existing Builiding or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. This requirement is not met as evidenced by
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Licensee stated to obtain the required permits to the city government for the alterations made of adding room on the second floor of the facility and notify & submit letter to CCLD of the alterations made and copy of the permit.
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Based on observation & interview and records review the licensee, did not comply with the section cited above by adding additional room on the second floor of the facility without notifing CCLD which pose potential health & safety risk to clients in care.
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Type B
01/05/2024
Section Cited
CCR80088(e)(1)

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80088 Furniture, Fixtures, Equipment, and Supplies (e) Faucets used by clients for personal care...(1)Hot water tempurature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water tempature of not less then 105 degrees F and not more then 120 degrees F. This requirement is not met as evidence by:
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Licensee stated to fix/ regulate the hot water temperature on clients shared bathroom between 105 degrees F to 120 degrees F and submit proof to CCLD on POC due date.
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Based on interview and records review and observations Licensee did not comply with the section cited above by having 151 degrees F hot water temperature on residents shared bathroom which is more than the requirement which pose potential health & safety and personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023


LIC809 (FAS) - (06/04)
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