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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880962
Report Date: 12/04/2024
Date Signed: 12/04/2024 12:34:10 PM

Document Has Been Signed on 12/04/2024 12:34 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:CASA VELAZQUEZ CARE LLCFACILITY NUMBER:
361880962
ADMINISTRATOR/
DIRECTOR:		MIRELIA VELAZQUEZFACILITY TYPE:
735
ADDRESS:14182 PARKVIEW DRTELEPHONE:
(909) 333-1789
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 3CENSUS: 3DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Nuria Gabriela Quintero, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analysts (LPAs) Becky Mann and Sarina Ramirez conducted an unannounced required 1-year visit to the facility. LPAs met with Nuria Gabriela Quintero, Assistant Administrator and discussed the purpose of the visit. The facility is an Adult Residential Facility, license capacity of 3 with a current census of 3 clients. LPAs conducted an overall inspection of the facility, which included, but was not limited to the following:

LPAs inspected the facility inside and out. Indoor and outdoor passageways are kept free of obstruction. Facility has no bodies of water. Facility backyard is fenced with self-latching gate. Facility has sufficient space for client indoor and outdoor activities. The facility has sufficient lighting and is maintained at a comfortable temperature.

LPAs inspected the kitchen. Facility has sufficient seven (7) days supply of non-perishable and two (2) days perishable food for number of clients in care. Facility food is stored in a safe and healthful manner. Facility has sufficient cups, plates, and utensils for client in use. Sharps, disinfectants, and chemicals are kept locked and inaccessible to clients in care.

LPAs inspected client bedrooms. Bedrooms are equipped with beds, mattresses, bed linens, night stands, chairs, storage space, and sufficient lighting.

LPAs inspected client bathrooms. Bathroom equipment is operating in safe and sanitary conditions. Hot water temperatures tested between 105 and 107 degrees Fahrenheit.

The facility is equipped with operating carbon monoxide and smoke alarms. Facility has posted in a common area the facility sketch, personal rights, disaster plan, and CCL complaint poster. Facility has sufficient supply of linens, towels, and hygiene products for clients in care.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CASA VELAZQUEZ CARE LLC
FACILITY NUMBER: 361880962
VISIT DATE: 12/04/2024
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LPAs inspected client medications. Medications are labeled and administered as prescribed. Medications are kept locked and inaccessible to clients in care.

LPAs reviewed client files for admission agreements, physician reports and record of client safeguarded resources. Client files are maintained and up to date.

LPAs reviewed staff files for criminal record clearances, first aid certifications, training, and health screenings. Facility's staff records are up to date.

No deficiencies were cited during today's visit per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, where the licensing reports LIC809 and LIC809C were discussed, and copies were provided to the Assistant Administrator at the conclusion of the visit.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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