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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880878
Report Date: 01/16/2025
Date Signed: 01/16/2025 01:55:21 PM

Document Has Been Signed on 01/16/2025 01:55 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:BIG HEARTS PARK, INC.FACILITY NUMBER:
361880878
ADMINISTRATOR/
DIRECTOR:		MAGLALANG, LOUELAFACILITY TYPE:
735
ADDRESS:25361 PARK AVETELEPHONE:
(909) 478-3738
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 4CENSUS: 4DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Caregiver Astrid Lesiasel TIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced required annual inspection to the facility. LPA met with Caregiver Astrid Lesiasel and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), level 4i. The facility is an Inland Regional Center (IRC) certified vendor with a license capacity of (4) and a current census of (4). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant & Operation: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pool or similar bodies of water. Facility's backyard is enclosed and gated. Indoor and outdoor activity areas are sufficient for clients in care. Client activities include community outings and day program participation. The facility has sufficient lighting and is maintained at a comfortable temperature. Client bathrooms were clean and free of odor. The hot water temperature in two (2) clients bathrooms measured at 122 degrees F, deficiency will be issued. Client bedrooms have sufficient lighting and furniture in good repair. Facility has operating smoke detector and carbon monoxide alarms, laundry equipment and telephone service. The facility has sufficient linens and personal hygiene items for clients in care. The facility has posted in a common area: facility license, weekly menu, facility sketch, client roster, activities calendar, liability insurance, client rights, and Administrator Certificate.



Food Service: The facility has sufficient non-perishable and perishable food supply for clients in care. Sharps and chemicals were kept locked inaccessible to clients in care.
**** Continuation on LIC 809 – C****
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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 3
Document Has Been Signed on 01/16/2025 01:55 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 01/16/2025 at 01:33 PM
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
RIVERSIDE, CA 92507

FACILITY NAME: BIG HEARTS PARK, INC.
FACILITY NUMBER: 361880878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, the licensee did not comply with the section cited above. Two client bathrooms hot water measured at 122 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Licensee has agreed to adjust the hot water temperature and send proof of correction to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


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: BIG HEARTS PARK, INC.
FACILITY NUMBER: 361880878
VISIT DATE: 01/16/2025
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Care & Supervision: Facility has 24 hour care staff. Staff working have criminal record clearances.

Record Review: Review of (4) Client files were observed to be complete. Review of (3) staff files were observed to be complete.

Medical Related Services: Client’s medications are labeled and centrally stored in a locked cabinet.

Based on observations and record review, deficiency was cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where the Licensing reports LIC 809, LIC 809C, and LIC 809D were discussed and copies of the reports with Appeal Rights was provided to Caregiver Astrid Lesiasel.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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