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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880561
Report Date: 12/05/2024
Date Signed: 12/05/2024 03:28:12 PM

Document Has Been Signed on 12/05/2024 03:28 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LAS PALMAS RESIDENTIAL CAREFACILITY NUMBER:
361880561
ADMINISTRATOR/
DIRECTOR:		MEDINA, RYANFACILITY TYPE:
735
ADDRESS:7128 LAS PALMAS DRTELEPHONE:
(909) 330-2231
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 3DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Administrator-Margarita MedinaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analysts (LPA Beena Singh arrived unannounced to conduct the required comprehensive annual visit to the facility. LPA Beena Singh met with Administrator Margarita Medina introduced herself and stated the purpose of the visit.

The facility has six (6) bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached garage. The facility is vendorized by Inland Regional Center (IRC). LPA Beena Singh completed a walk through of the facility, review of records, medication audit and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL), LPA Singh observed three (3) clients. There are no obstructions to indoor & outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees F. LPA Singh inspected client bedrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested 115 degrees F. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. Sharps and medications were kept in secure cabinets inaccessible to clients. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. Overall, the facility is clean, and operates in safe conditions for clients in care.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LAS PALMAS RESIDENTIAL CARE
FACILITY NUMBER: 361880561
VISIT DATE: 12/05/2024
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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard. The outdoor pathway on the side of the facility was free of obstructions.

Food Service: LPAs observed two (2) day(s) supply of perishable food and seven (7) day(s) of supply of non-perishables food and snacks. Dishes, cups and utensils were stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 4 hours a day, 7 days a week.

Record Review: LPA Beena Singh reviewed client files for Admission Agreements, Needs and Services Plans, Functional Capabilities, Pre-placement Appraisal and Physician Report, C1, C2, C3 Needs and Services Plan, Functional Capabilities and Pre-placement Appraisal in their facility file LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, training's, and health screenings and Tuberculosis (TB) Test result. LPA reviewed P&I records and LPA observed no issue. LPA Beena Singh reviewed Clients medications matched with MARS. LPA Singh observed no issue.

No deficiencies were cited during the visit. An exit interview was conducted where this report were discussed with Administrator Margarita Medina and copies were provided to Staff.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
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