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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880781
Report Date: 10/03/2023
Date Signed: 10/03/2023 02:53:56 PM

Document Has Been Signed on 10/03/2023 02:53 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:DIGNITY ADULT DAY CAREFACILITY NUMBER:
361880781
ADMINISTRATOR:KARAPETYAN, ALINAFACILITY TYPE:
775
ADDRESS:4110 HOLT BLVD, UNIT BTELEPHONE:
(909) 447-1313
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY: 50CENSUS: 0DATE:
10/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Alina KarapetynTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Facility Administrator Alina Karapetyn and was granted entry to the facility. The facility is an Adult Day Program (ADP) Facility Licensed capacity is (50) current census (0). LPA was accompanied by Facility Administrator, to conduct 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. LPA inspected facility bathrooms, kitchen area, and activity rooms. LPA observed facility to be 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 at 106.9 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, were posted in a common area. Cleaning supplies, toxins, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications will be kept inside well-ness office inaccessible to clients. Overall, the facility is clean, in good repair.

Food Service: Facility currently has a census of zero (0) LPA observed Non-perishable/snacks to be stored.

Care & Supervision: Facility currently has no staff working at the facility.

Record Review: LPA reviewed administrators file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Alina Karapetyn.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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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