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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800159
Report Date: 12/06/2023
Date Signed: 12/06/2023 10:46:00 AM

Document Has Been Signed on 12/06/2023 10:46 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
, CA 92507
FACILITY NAME:YUCAIPA RESIDENTIAL CAREFACILITY NUMBER:
361800159
ADMINISTRATOR:CRUZ, ARIEL DELAFACILITY TYPE:
735
ADDRESS:33556 BRUSHY HOLLOW DRIVETELEPHONE:
(949) 337-8601
CITY:YUCAPASTATE: CAZIP CODE:
92399
CAPACITY: 5CENSUS: 4DATE:
12/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Juan Ramirez-Care StaffTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and allowed entry into the facility by Juan Ramirez.

The facility has four (4) bedrooms and two (2), bathrooms, kitchen/dining area, living room. The facility is an Adult Residential Facility (ARF) level 4I home vendored by Inland Regional Center. LPA conduct a general overall inspection,which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms which are equipped with required furniture such as: mattresses, night-stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility.

LPA measured and observed the water temperatures in the bathrooms to be between 105.7 -120 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide detectors. Posters such as personal rights, he CCL complaint poster, and the disaster plan were posted in main hallway area.

Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care locked in the garage. There was a designated storage space for client/staff files.

Medications are kept inside the cabinet in the main hallway area. Overall, the facility is clean, in good repair, and operates in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for the number of clients in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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 3
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: YUCAIPA RESIDENTIAL CARE
FACILITY NUMBER: 361800159
VISIT DATE: 12/06/2023
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Record Review: LPA reviewed three (3) client files for admission agreements, physician reports, and needs and services plans. Based on LPA review of client’s files there was no current physician reports or needs and service plans for the clients in care.

LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

Medications were audited at random and appeared to be dispensed appropriately by staff members. PNI funds were counted for and matched with the ledger.

Based on the observations made during today’s visit a technical advisory was cited because the clients files were not current during the annual visit. The licensee has agreed to update the clients files with all required documents a technical advisory was cited during the annual inspection.

An exit interview was conducted, and this report was discussed and provided to Juan Ramirez at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC809 (FAS) - (06/04)
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