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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881045
Report Date: 11/04/2022
Date Signed: 11/04/2022 11:20:28 AM

Document Has Been Signed on 11/04/2022 11:20 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SAHARIA CARE HOMES INC.FACILITY NUMBER:
361881045
ADMINISTRATOR:MATHUR, BHARTIFACILITY TYPE:
735
ADDRESS:7531 STONEY CREEK DRIVETELEPHONE:
(909) 856-9921
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 4CENSUS: 4DATE:
11/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Lisnah Illyes, DSPTIME COMPLETED:
11:25 AM
NARRATIVE
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LPA Amber Coleman (LPA Coleman) and LPA Anna Bueno (LPA Bueno) arrived at the Saharia Care Home Facility to make a case management visit based on an Incident Report filed on September 29th, 2022. Incident Report indicated a consumer ingested 2 AAA batteries. LPAs completed records review, staff interviews and telephone calls during the visit.

LPA's Coleman and Bueno were greeted by staff member Lisnah Illyes, DSP (S1) who invited LPAs inside the Facility. S1 reported that the current census is 4. At time of the visit consumers were out of the home at their prospective day programs. S1 contacted House Manager Sachin contacted LPA during the visit. LPA Bueno House Jay Ruba who reported that S1 informed him of the incident on 9/29/22 and where to locate the documentation for the incident. Records review revealed that the the House Mgr. arrived to facility at 10:25am to verify there is a plan in place to provide additional support to the consumer. Administrator contacted LPA who confirmed the interventions staff has put in place to address the consumer's behavior. Documentation reviewed supported interventions put in place. LPA Bueno also discussed the importance of staff supervision LPA Bueno walked through the consumer's rooms which was observed to be free of debris and objects that pose potential hazard. House Mgr. explained interventions and training in place to keep consumers safe. LPA Coleman walked through facility and observed it to be cleanly and orderly.

Based on interviews and observations, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed and provided to Jay Ruba, House Manager at the conclusion of the inspection.
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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