<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880704
Report Date: 05/07/2024
Date Signed: 05/07/2024 12:00:37 PM

Document Has Been Signed on 05/07/2024 12:00 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:SULE'S LOVING HOMEFACILITY NUMBER:
361880704
ADMINISTRATOR/
DIRECTOR:		JEANETTE GARCIAFACILITY TYPE:
735
ADDRESS:7640 TOKAY AVETELEPHONE:
(909) 329-9740
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 3DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Licensee/Administrator Sulema ParraTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/07/2024 at 9:10 AM, Licensing Program Analyst (LPAs) Melody Brown and Sarina Ramirez conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Brown and Ramirez were greeted by a Licensee/Administrator Sulema Parra and gained access at the home.LPAs Brown and Ramirez explained the purpose of the visit to Licensee/Administrator Parra.

The facility has Three (3) bedrooms, Two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPAs Brown and Ramirez completed a walkthrough of the facility, review of records, P and I audit, and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Brown and Ramirez observed no client(s) during the visit. Licensee/Administrator Parra reported that all their three (3) clients’ were out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 68 degrees Fahrenheit. LPAs Brown and Ramirez inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Brown and Ramirez inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 144 degrees Fahrenheit, deficiency will be issued. 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, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Brown and Ramirez observed night lights at the hallway leading to clients' shared bathroom. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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 5
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: SULE'S LOVING HOME
FACILITY NUMBER: 361880704
VISIT DATE: 05/07/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Moreover, during the tour of the facility, LPAs Brown and Ramirez observed three (3) knives inside kitchen cabinet not locked and accessible to clients in care. Also, one (1) scissor observed in the kitchen not locked and accessible to clients in care. Deficiency will be issued.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

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


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPAs Brown and Ramirez reviewed three (3) client files for admission agreements, medical assessments/physician reports,and Individual Program Plan (IPP). LPAs Brown and Ramirez observed that Client 2 (C2) does not have medical assessment on C2 facility file. Licensee/Administrator Parra reported that C2 was placed by Inland Regional Center (IRC) to the facility on 2/16/24 with out medical assessment. Deficiency will be issued. LPAs Brown and Ramirez also reviewed three (3) staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs Brown and Ramirez observed no issues, files reviewed were complete.

LPAs Brown and Ramirez audited two (2) clients’ medications and no issues were observed. LPAs Brown and Ramirez audited two (2) client's P&I and no issue observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, and Appeal Rights were discussed, and copies were provided to Licensee/Administrator Sulema Parra.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/07/2024 12:00 PM - It Cannot Be Edited


Created By: Melody Brown On 05/07/2024 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SULE'S LOVING HOME
FACILITY NUMBER: 361880704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the three (3) knives and one (1) scissor in the kitchen were locked and not accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
1
2
3
4
Licensee immediately locked the three (3) knives and one (1) scissor found in the kitchen during the visit.
Licensee stated to train all staff on CCR 80087(g) and submit proof of training log to LPA Brown on plan of correction (POC) due date.
Type A
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by accepting Client 2 (C2) at the facility without the required medical assessment on 2/16/24 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
1
2
3
4
Licensee stated to submit proof of C2 medical appointment to complete C2 medical assessment to LPA Brown on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/07/2024 12:00 PM - It Cannot Be Edited


Created By: Melody Brown On 05/07/2024 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SULE'S LOVING HOME
FACILITY NUMBER: 361880704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not regulating the hot water in client shared bathroom of not less than 105 degrees F and not more than 120 degrees F as required which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
1
2
3
4
Licensee stated to regulate the hot water in client shared bathroom to not less than 105 degrees F and not more than 120 degrees F as required and submit proof to LPA Brown on Plan of correction (POC) due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5