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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881272
Report Date: 05/25/2022
Date Signed: 05/25/2022 12:05:16 PM

Document Has Been Signed on 05/25/2022 12:05 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:ST. CLARE FAMILY HOMEFACILITY NUMBER:
361881272
ADMINISTRATOR:TAN, CARLITOFACILITY TYPE:
735
ADDRESS:2608 GARFIELD AVENUETELEPHONE:
(909) 472-1767
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 4CENSUS: 0DATE:
05/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Antonio SanchezTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Jennifer Semin conducted an announced visit to complete a pre-licensing inspection and component III. LPA met with Licensee Antonio Sanchez. The application is for a Adult Residential Facility for four (4), 2 (two) ambulatory and two (2) non-ambulatory clients.
A tour of the pending facility was conducted inside and out. Overall, the pending facility is clean and of new construction. There no pools, bodies of water, firearms or ammunition. LPA observed all bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, showers and tubs have non-skid mats. The hot water temperature was measured in the clients bathroom at 109 degrees Fahrenheit. LPA observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer temperatures are maintained at appropriate temperatures. All appliances are clean and operating properly. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present including a First Aid Manuel. LPA observed a minimal supply of recreation and leisure items and activities. The backyard is completely enclosed with functioning gate to exit to front yard. Outdoor space is suitable for client use that includes a covered patio, with a table and chairs. LPA observed the fire extinguishers to be recently serviced and completely charged. Smoke alarms and carbon monoxide detectors are present and functional. Medications will be centrally stored and secured in a locked cabinet. All hazardous materials such as, cleaning and disinfecting supplies, knives and other sharps are locked and inaccessible to clients. All required forms are posted in a common area.
Pre-Licensing is complete and has no deficiencies.
Mr. Sanchez was reminded of the statute that requires the licensee to contact LPA at CCLD 951-473-7024 within 5 business days of admitting their first client. This notification may be done by phone, mail or fax.

An exit interview was conducted where this report was discussed and provided to Mr. Sanchez.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
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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