361881069-6-13-2023-56-AS-MMAE-CSRUN5-20230613154323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881069
Report Date: 06/13/2023
Date Signed: 06/13/2023 03:43:27 PM

Document Has Been Signed on 06/13/2023 03:43 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:	NABIH'S CARE HOME		FACILITY NUMBER:	361881069
ADMINISTRATOR:	DINEROS, OLIVER		FACILITY TYPE:	735
ADDRESS:	407 W. SPRUCE ST		TELEPHONE:	(909) 996-2108
CITY:	ONTARIO	STATE: CA	ZIP CODE:	91762
CAPACITY:	4	CENSUS: 0	DATE:	06/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Oliver Dineros, Administrator		TIME COMPLETED:	03:50 PM

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Licensing Program Analyst (LPA) Magda Malcore conduct a required annual inspection of the facility. LPA met with Oliver Dineros, Administrator and discussed the purpose of the visit. At the time of the visit there were no clients and no staff at the facility. Facility is Inland Regional Center (IRC) certified and pending clients.

The facility is an Adult Residential Facility (ARF) with (4) bedrooms, (2) bathrooms, kitchen/dining area, a living room and attached garage. The facility is licensed for (4) ambulatory clients with a current census of (0). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPA observed indoor and outdoor passageways were kept free of obstruction. The backyard area has sufficient patio furniture in good repair. The facility has no bodies of water. Facility has sufficient living room and dining room furniture in good repair. The facility has sufficient lighting and is maintained at a comfortable temperature 70 degrees F.

LPA inspected the kitchen. Facility has sufficient nonperishable and perishable food which is stored in a safe and healthful manner. Facility has weekly menus posted in common area. Facility has sufficient utensils, cups and plates. Sharps are stored and kept locked in kitchen drawers, inaccessible to potential clients in care.

LPA inspected (4) client bedrooms. The bedrooms are equipped with required furniture such as: mattresses, night stands, a chair, storage space, and sufficient lighting.

LPA inspected (2) bathrooms. Bathrooms were operating in a safe and sanitary condition. The hot water temperature tested within regulation at 108 degrees F.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NABIH'S CARE HOME	FACILITY NUMBER: 361881069
	VISIT DATE: 06/13/2023

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LPA observed a sufficient amount of books, magazines, games for client activities. Facility has a sufficient supply of towels and linen stored in a hallway cabinet. Facility laundry equipment is fully operational.

LPA observed the facility is equipped with operating carbon monoxide alarms and fully charged fire extinguisher. Posters such as personal rights, complaint poster, and disaster plan were posted in a common area. Cleaning supplies, toxins items will be kept locked and inaccessible to potential clients in care.

LPA observed where medications will be kept once residents are admitted to the facility. The medication cabinet is locked and inaccessible to potential clients in care. Facility has a complete first aid kit and emergency supplies. Overall, the facility is clean, in good repair, and operating in safe conditions.

Facility currently has no clients and/or staff files to review at the time of visit as the facility has no clients in care. LPA observed a file cabinet which will be used for staff and clients files.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed, and a copy of this report was provided to the administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC809 (FAS) - (06/04)

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