361880997-11-4-2020-18-AS-KWIS-BV2QDF-20201104110440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880997
Report Date: 11/02/2020
Date Signed: 11/04/2020 11:04:47 AM

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
RIVERSIDE, CA 92507

FACILITY NAME:	HAMPSHIRE HOME SENIOR CARE, LLC		FACILITY NUMBER:	361880997
ADMINISTRATOR:	RAMAS III, SOTERO CHANDLER		FACILITY TYPE:	740
ADDRESS:	1635 HAMPSHIRE RD.		TELEPHONE:	(661) 319-6671
CITY:	SAN BERNARDINO	STATE: CA	ZIP CODE:	92404
CAPACITY:	6	CENSUS: 6	DATE:	11/02/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Chandler Ramas III		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kathleen Wiggins conducted an announced pre-licensing video conference inspection to the facility due to COVID-19. LPA met with Chandler Ramas and Fe Elias. Currently there are six (6) residents in care. The facility is a single story house consisting of (5) bedrooms including a room for a live in caregiver, (4) bathrooms, a living room, kitchen with dining area, laundry room, a sauna located in the master bedroom however it is locked and the residents will not be using it. There is also a backyard and garage. On 8/06/20, the San Bernardino Fire Department approved the facility for (6) residents: 1 of which may be ambulatory and 5 non-ambulatory. The medications are centrally stored in a cabinet in the kitchen next to the refrigerator. The sharps are locked in a tool box under the in a cabinet next to the kitchen sink. The physical plant is in good repair. The facility is equipped with night lights in the hallways and passages. The smoke detectors and carbon monoxide detectors were tested and are operable. There were 3 fully charged fire extinguishers. The cleaning supplies will be locked in a cabinet in the laundry room. All doors, and passageways are clear from obstruction have an alarm (delayed egress device). There is a screened fire place located in bedroom #5. The facility maintained a comfortable temperature throughout the inspection. All beds have the required linen and supplies. There was a sufficient amount of clean linen. There was appropriate lighting for the use of each room. The hot water tested at 113.9 degrees F, measuring within regulatory limits. All kitchen appliances operate properly. The phone number designated for the facility is (909) 804-2121. There is an emergency exit, free of obstruction. There is a black bottom pool with a water fall, that is surrounded by a locked gate located in the backyard. The bathrooms are equipped with grab bars and non-skid floor mats and/or surfaces. The facility was equipped with operable laundry equipment. The facility is equipped with emergency flashlights. All garbage cans have tight fitted lids.

SUPERVISOR'S NAME: Leslie Mendiveles	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR NAME: Kathleen Wiggins	TELEPHONE: (951) 205-7142
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020

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
RIVERSIDE, CA 92507

FACILITY NAME: HAMPSHIRE HOME SENIOR CARE, LLC	FACILITY NUMBER: 361880997
	VISIT DATE: 11/02/2020

NARRATIVE

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The facility is stocked with a two-day supply of perishables and a seven-day supply of non-perishable food items. The facility was stocked with dishes, tableware, and utensils in good repair and enough for the capacity. The resident and staff files will be locked in a 4 drawer file cabinet located in a locked room inside of the garage. LPA observed an emergency disaster plan, personal rights, and complaint procedures and required telephone numbers that are posted throughout the facility. There was adequate seating in the common areas. There are 2 stocked first aid kits with a manual. The facility is stocked with activities for the residents.

The facility was evaluated in accordance with the CCR, Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of clients in care. Facility appears to be ready for licensure.

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

Receipt of report was confirmed.

SUPERVISOR'S NAME: Leslie Mendiveles	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR NAME: Kathleen Wiggins	TELEPHONE: (951) 205-7142
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020

LIC809 (FAS) - (06/04)

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