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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880699
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:27:12 PM

Document Has Been Signed on 09/14/2023 03:27 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:NOLA HOMESFACILITY NUMBER:
361880699
ADMINISTRATOR:WILSON, ASIAFACILITY TYPE:
735
ADDRESS:5975 FOREST OAKS PLTELEPHONE:
(310) 658-4856
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 2DATE:
09/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Asia WilsonTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility to conduct a required annual inspection. LPA identified herself to licensee Asia Wilson who was advised of the purpose of the visit. The facility is currently licensed as an Adult Residential Facility, vendored by the Inland Regional Center. The facility has capacity of four ambulatory clients. Two clients were present during today's visit.

LPA Bueno and Licensee Wilson toured the interior and exterior of the facility. The facility has no bodies of water. There is a shaded seating area for clients. LPA and Licensee observed that side gates were unlocked and free of obstruction. The facility had a working telephone for client use. The facility fire extinguisher was last inspected on 03/16/2023. Licensee tested interconnected smoke alarms and a separate carbon monoxide detector and LPA and Licensee found all units to be in working order. A locked centralized closet is utilized for medications while client files are secured and locked in a standing closet. Sharps, toxins, and cleaning agents are kept secured.

The following were observed of the physical plant:
Client Bedrooms and Bathroom: LPA and Licensee observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. The facility had a supply of additional linens. LPA and Licensee observed bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients. The facility keeps a supply of hygiene provisions.
Kitchen and Dining Areas: LPA and Licensee inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. The facility menu is available for review. LPA and Licensee observed two (2) days supply of perishable food items and seven (7) days supply of nonperishable food items. The facility menu was available for review. The kitchen countertop, floors, and appliances were free from debris.
Common (living/activity) areas: LPA and Licensee observed adequate seating in the common areas. The facility had a supply of activities for the clients. Calendar of activities were reviewed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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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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: NOLA HOMES
FACILITY NUMBER: 361880699
VISIT DATE: 09/14/2023
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The following records were inspected:
Client Records: LPA inspected two of two client files and found that it had the required documentation including an admissions agreement, physician's report, and current Individual Program Plan (IPP).
Staff Records: LPA reviewed two staff files and found current first aid certifications and training verifications. The administrator certificate is up to date.
Centralized Medication: LPA reviewed two of two client medications and found that the medication is being administered as prescribed. No client is receiving injectable medication.
LPA also reviewed updated LIC500, personnel report, and LIC610E, emergency disaster plan.

No deficiencies were issued during today's visit. An exit interview was conducted where this report was discussed and a copy was provided to Licensee Wilson at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC809 (FAS) - (06/04)
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