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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800159
Report Date: 12/16/2024
Date Signed: 12/16/2024 09:47:23 AM

Document Has Been Signed on 12/16/2024 09:47 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/
DIRECTOR:		CRUZ, ARIEL DELAFACILITY TYPE:
735
ADDRESS:33556 BRUSHY HOLLOW DRIVETELEPHONE:
(949) 337-8601
CITY:YUCAPASTATE: CAZIP CODE:
92399
CAPACITY: 5CENSUS: 4DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Juan Ramirez.-House ManagerTIME VISIT/
INSPECTION COMPLETED:
10:00 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 conducted 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 70 degrees. 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, the 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 and hallway closet. 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.

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: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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: YUCAIPA RESIDENTIAL CARE
FACILITY NUMBER: 361800159
VISIT DATE: 12/16/2024
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Record Review: LPA reviewed two (2) client files for admission agreements, physician reports, and needs and services plans/IPP.

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 audited and based on LPA observations the funds matched with the ledger.

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

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

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
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