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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880901
Report Date: 07/25/2024
Date Signed: 07/25/2024 05:02:39 PM


Document Has Been Signed on 07/25/2024 05:02 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:B SMITH BOARD AND CAREFACILITY NUMBER:
361880901
ADMINISTRATOR:SMITH, BRITTNEYFACILITY TYPE:
740
ADDRESS:10583 PORTLAND AVETELEPHONE:
(909) 244-4280
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:4CENSUS: 0DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Brittney Smith - AdministratorTIME COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted a required annual inspection of the facility. LPA met with Brittney Smith, Administrator, and discussed the purpose of the visit.
The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (4). The facility currently has no residents in care, the most recent resident left 3 days ago to live with family. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:
Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathroom equipment were operating in a safe and sanitary condition. The hot water temperature in residents' bathrooms measured at 105 degrees F. Resident’s bedrooms had beds, chairs, night stands, and sufficient storage space. The facility has operating carbon monoxide alarms and telephone service. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, Personal Rights, disaster evacuation plan and emergency telephone numbers. Sharps, disinfectants, and cleaning solutions were kept in a locked closet.
Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply. The facility has sufficient cups and plates for residents to use.
Medical Related Services/File Review: Current there are no residents in care, LPA observed a locked central area for medication storage. The facility has a complete first aid kit. Two (2) staff files were observed to be complete and included criminal record clearances through the Department.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: B SMITH BOARD AND CARE
FACILITY NUMBER: 361880901
VISIT DATE: 07/25/2024
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No deficiencies were cited during today’s visit. An exit interview was conducted where this report was discussed and a copy provided to the Administrator at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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