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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880686
Report Date: 10/28/2022
Date Signed: 12/30/2022 02:21:41 PM

Document Has Been Signed on 12/30/2022 02:21 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HELPING HEARTS BLACKWOODFACILITY NUMBER:
361880686
ADMINISTRATOR:CESAR ARGUETAFACILITY TYPE:
772
ADDRESS:11253 BLACKWOOD STTELEPHONE:
(909) 677-6644
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 6CENSUS: 6DATE:
10/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH:Felipe Ybarra & Daniel GomezTIME COMPLETED:
03:55 PM
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LPA Amber Coleman (LPA Coleman) and LPA Anna Bueno (LPA Bueno) arrived at the Helping Hands Blackwood to make an unannounced visit for an annual inspection with a focus on Infection Control. Staff Member Felipe opened the door and invited LPA inside. Staff asked that LPAs sign in and complete a temperature check. COVID station was stocked with sufficient PPE, disinfectant and hand sanitizer. LPA explained the purpose of the visit and asked for a walk through. The current census of the facility is 6. There are 4 male consumers and 2 female consumers; who were all present during the visit along with 1 other staff member. Felipe contacted the Program Director, Daniel Gomez who arrived during the walk through as well as Blythe McClananhan, Supervising Program Director.

During the walk through, LPA's observed the following. The facility was clean, orderly and of suitable temperature. The facility has 4 rooms. 2 client's occupy 3 rooms with the 4th room as the staff office. Each room was equipped with adequate furniture and storage space. Bathrooms were observed to be cleanly with accessible soap and paper towels. Laundry room was in working condition. Extra hygiene supplies, sufficient PPE, chemicals and sharps were located in a secure closet in the hallway. Medication was observed to be stored in a secure in a file cabinet. LPA's tested both fire alarms and carbon monoxide detectors which were found to be in proper function. Last inspection for the fire extinguishers (2) was done on July 13th, 2022. The kitchen, den and dining areas were orderly with adequate seating available. LPA observed a sufficient amount of both perishable and non-perishable food found in the pantry, refrigerator and deep freezer.
LPA noticed signage for infection control, house rules, activities, food menu, emergency evacuation plan, and licensing policies posted throughout the facility. A review of records revealed that staff have not been fit tested for the N95.

Based on interviews and observations made during today’s inspection a technical advisory was issued due to staff not being N95 Fit Tested. An exit interview was conducted where this report was discussed and a copy of this report was provided to Daniel Gomez, Program Director and Blythe McClanahan, Supervising Program Director at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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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