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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881078
Report Date: 03/26/2021
Date Signed: 03/26/2021 12:38:06 PM

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:SUMMER DREAMS ASSISTED LIVING, LLCFACILITY NUMBER:
361881078
ADMINISTRATOR:DELFIN, RANIERFACILITY TYPE:
740
ADDRESS:7425 HELLMAN AVETELEPHONE:
(909) 919-9246
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:6CENSUS: 5DATE:
03/26/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rainier DelfinTIME COMPLETED:
10:30 AM
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Licensing Program Analysts (LPA) Pauline Beschorner conducted an announced pre-licensing inspection to the facility via Microsoft Teams. During the pre-licensing inspection LPA also conducted the Component III. LPA met with Licensee/Administrator Rainier Delfin.

The facility is currently operating. LPA observed 5 residents present in the home. The home is a four bedroom, two bath home with a living room, dining room and kitchen. Per the approved fire clearance, the licensee is approved for 5 non-ambulatory and 1 bedridden resident. All bedrooms are furnished with bed, night stand, dresser and chair and have adequate lighting for residents use. The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The bathrooms were inspected to have grab bars and non-skid mats/flooring installed for resident safety. The water temperature was tested and measured at 113.5 degrees Fahrenheit. A centralized smoke detector was observed and operable. The facility has 2 carbon monoxide alarms installed and operable. LPA observed a fully charged fire extinguisher present in the facility. The kitchen was observed to have dishes, silverware, pots and pans. LPA observed the locked cabinet in which the medications will be kept. LPA observed the knives and cleaners to be locked in the garage. A complete first aid kit was observed and to be complete. The backyard was observed to be fully fenced with an unlocked gate. The backyard also had a large patio cover with chairs and a table for the residence comfort. LPA also observed a swimming pool which was behind a locked gate.

An exit interview was conducted and a copy of this report was reviewed and provided to Licensee/Administrator Rainier Delfin.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
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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