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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881078
Report Date: 07/12/2021
Date Signed: 07/12/2021 11:01:53 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: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:
07/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Karen Delfin, CaregiverTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Tricia Danielson arrived to the facility to conduct a case management visit to check on the health, safety, and welfare of residents in care. LPA was greeted and granted entry to the facility by Caregiver Karen Delfin. LPA explained the purpose of the visit. There are five (5) residents currently residing at this facility. There was one (1) staff on duty and one (1) hospice worker present during the time of the visit.

During the visit, LPA toured the inside and outside of the facility. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. The food was observed to be of adequate quality and have proper nutritional value. LPA tested water temperatures which were found to be within regulatory requirements. Smoke and carbon monoxide detectors were also observed to be in working order. LPA toured resident rooms and observed the rooms to have adequate lighting, appropriate linens, and adequate personal storage space. Facility doorways and pathways were observed to be free from obstructions. The inside temperature was measured and was within regulatory requirements.

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Delfin.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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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