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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881204
Report Date: 02/28/2025
Date Signed: 02/28/2025 11:40:06 AM

Document Has Been Signed on 02/28/2025 11:40 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PITACHE RESIDENTIALFACILITY NUMBER:
361881204
ADMINISTRATOR/
DIRECTOR:		WILLIAMS, NATALIEFACILITY TYPE:
735
ADDRESS:18025 PITACHE ST.TELEPHONE:
(909) 671-2812
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 4CENSUS: 4DATE:
02/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Magdalena RamirezTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 02/28/2025 at 9:03AM, Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA was greeted by a staff and gained access to the home. Licensee/Administrator Magdalena Ramirez was contacted and informed that Community Care Licensing (CCLD) was at the facility. LPA explained the purpose of the visit to Licensee/Administrator Magdalena Ramirez.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA completed a walk through of the facility, review of records, Personal and Incidentals (P&I) and medications audit.



Physical Plant: The facility is operating in the capacity approved by CCLD. LPA observed one (one) client during the visit. Three (3) clients’ out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 62 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 117 degrees Fahrenheit. The facility is equipped with operational smoke detectors, a carbon monoxide detector, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, labor laws, and emergency disaster plan were posted in a common area. Client medications were kept in secure closet inaccessible to clients. LPA observed a night light in the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PITACHE RESIDENTIAL
FACILITY NUMBER: 361881204
VISIT DATE: 02/28/2025
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Yards/Outside: A large tree and umbrella serve as a shaded area, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA Small observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed four(4) client files for admission agreements, medical assessments/physician reports and Individual Program Plan (IPP). LPA observed files reviewed were complete. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. Staff files were complete. .

LPA Small audited four (4) clients’ medications and no issues were observed. LPA audited four (4) client's Personal and Incidental (P&I) and no issues were observed.

A Technical Assistance was given during this visit. An exit interview was conducted where this report LIC809, LIC809C, were discussed, and copies were provided to Licensee/Administrator Magdalena Ramirez.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC809 (FAS) - (06/04)
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