361881229-1-16-2024-56-AS-MMAE-CZJQLR-20240116111622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881229
Report Date: 01/16/2024
Date Signed: 01/16/2024 11:16:32 AM

Document Has Been Signed on 01/16/2024 11:16 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:	ADORA CARE		FACILITY NUMBER:	361881229
ADMINISTRATOR:	VANG, CHE LIYE		FACILITY TYPE:	740
ADDRESS:	1543 N UNIVERSITY ST		TELEPHONE:	(909) 894-4234
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92374
CAPACITY:	6	CENSUS: 6	DATE:	01/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Che Liye Vang - Administrator		TIME COMPLETED:	11:20 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Che Liye Vang, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6) and a current census of (6) residents in care. The facility has a hospice waiver for (6) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. The facility's outdoor area is fenced and sufficient for resident activities. The facility has sufficient indoor space and lighting for resident activities. The facility has operating telephone service, carbon monoxide alarms, and is maintained at a comfortable temperature. Resident’s bathrooms were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured 110 and 118 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, resident activities, disaster plan and emergency telephone numbers.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

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: ADORA CARE	FACILITY NUMBER: 361881229
	VISIT DATE: 01/16/2024

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Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas.

Care & Supervision: Facility has 24-hour, 7-days a week staff supervision. Staff working have criminal record clearances or exemptions through the Department.

Record Review: Staff files reviewed at random were observed to be complete. Resident files reviewed at random were observed to be complete. Administrator’s certification expires on 3/25/2024.

Medical Related Services: The facility has a complete first aid kit. All medication is centrally stored and kept in a locked cabinet.

Based on LPA observations and record review, no deficiencies were cited during today’s visit.

An exit interview was conducted where reports LIC809 and LIC809C were discussed with the Administrator. Copies of the reports were 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: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

LIC809 (FAS) - (06/04)

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