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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880962
Report Date: 12/04/2023
Date Signed: 12/04/2023 11:40:49 AM

Document Has Been Signed on 12/04/2023 11:40 AM - 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: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:
12/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Melanie MorrisTIME COMPLETED:
11:42 AM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility to conduct a required annual inspection. LPA identified herself to direct support provider (DSP) Diana Bojorquez who was advised of the purpose of the visit. The facility is currently licensed as an Adult Residential Facility, vendored by the Inland Regional Center. The facility has capacity of three ambulatory clients however no client was present during today's visit. DSP phoned administrator Melanie Morris who arrived at the facility during the visit.

LPA Bueno and DSP Bojorquez toured the interior and exterior of the facility. The facility has no bodies of water. There is a covered patio area. LPA and DSP observed that side gate is unlocked and free of obstruction. The facility has a working telephone for use. The facility fire extinguisher was last inspected on 09/13/2023. DSP tested all bedroom and hallway smoke alarms and LPA tested carbon monoxide detector. All units were found to be in working order. Medications and facility files are kept in centralized locked cabinets. Sharps, toxins, and cleaning agents are kept locked and secured.

The following were observed of the physical plant:
Client Bedrooms and Bathrooms: LPA Bueno and DSP observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. The facility had a supply of additional linens. LPA and DSP observed bathroom appliances were operating in safe and sanitary conditions. The facility keeps a supply of hygiene provision locked.
Kitchen and Dining Areas: LPA and DSP inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. The facility menu is available for review. LPA observed two (2) days supply of perishable food items and seven (7) days supply of nonperishable food items. The kitchen countertop, floors, and appliances were free from debris.
Common (living/activity) areas: LPA and Licensee observed adequate seating throughout the facility. The facility keeps a supply of activities for the clients and LPA observed clients have their personal items in their own rooms. Calendar of activities is posted in the common area.

The following records were inspected:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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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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: CASA VELAZQUEZ CARE LLC
FACILITY NUMBER: 361880962
VISIT DATE: 12/04/2023
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Client Records: LPA inspected three client files and found that required documentation including clients' rights, admissions agreement, physician's report, and Individual Program Plan (IPP).
Staff Records: LPA reviewed two staff files and found current first aid certifications and training verifications. The administrator certificate is current.
Centralized Medication: LPA reviewed three client medications and found that the medication is being administered as prescribed. LPA observed an updated LIC 500 personnel report, and LIC 610E, emergency disaster plan.

No deficiencies were issued during today's visit. An exit interview was conducted where this report was discussed and a copy was provided to administrator Morris at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
LIC809 (FAS) - (06/04)
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