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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880962
Report Date: 11/04/2022
Date Signed: 11/04/2022 02:21:15 PM

Document Has Been Signed on 11/04/2022 02:21 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:CASA VELAZQUEZ CARE LLCFACILITY NUMBER:
361880962
ADMINISTRATOR:MIRELIA VELAZQUEZFACILITY TYPE:
735
ADDRESS:14182 PARKVIEW DRTELEPHONE:
(909) 333-1789
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 3CENSUS: 3DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Charity Chukwulere, CaregiverTIME COMPLETED:
02:25 PM
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LPA Amber Coleman (LPA Coleman) and LPA Anna Bueno (LPA Bueno) arrived at the Casa Velazquez Facility to complete an Annual Inspection with a focus on Infection Control. Staff member, Charity (S1) greeted LPAs at the door and invited LPA inside facility. LPAs made introductions and discussed the purpose of the visit. Administrator Mariela Velazquez was phoned during visit and informed of LPAs visit. S1 requested LPA's have temp. taken and sign in. Front door table had proper PPE and hand sanitizer available. S1 was observed wearing proper PPE.

S1 and LPA's made a walk through the facility. Facility is a 3 bedroom and 2 bathroom home. Three clients were present during LPA visit. Proper COVID signage was displayed throughout facility. Bathrooms included efficient soap, paper supplies and wastebaskets. Fire and Carbon Monoxide alarms were tested and found to be in working order. Fire Extinguisher last inspected Sept. 23rd, 2022. All client rooms were observed to be orderly and supply adequate furniture. Medications, chemicals and sharp objects were observed to be centrally stored in a secure file cabinet. The backyard contained a shady area with accessible patio furniture. The facility owns a pet cat which is kept in the backyard outside. The kitchen stored adequate amounts of perishable and non-perishable food. Activity Calendar and Food Menus were observed posted in the kitchen.

Based on interviews and observations made during today’s inspection a technical advisory was issued due to staff not being N95 Fit Tested.

An exit interview was conducted, and a copy of this report was reviewed and provided to Charity Chukwulere via email to obtain signature.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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