361881288-7-29-2023-56-AS-PGUO-CU7THB-20230729144428

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881288
Report Date: 07/29/2023
Date Signed: 07/29/2023 02:44:34 PM

Document Has Been Signed on 07/29/2023 02:44 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	IRA CARE		FACILITY NUMBER:	361881288
ADMINISTRATOR:	FORMELOZA, ROWENA		FACILITY TYPE:	740
ADDRESS:	1598 BRENTWOOD AVE		TELEPHONE:	(909) 527-5757
CITY:	UPLAND	STATE: CA	ZIP CODE:	91786
CAPACITY:	6	CENSUS: 4	DATE:	07/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Rowena Formeloza		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Facility Administrator Rowena Formeloza and was granted entry to the facility. At the time of the visit there was two (2) staff present, and four (4) residents present. The facility is a four (4) bedroom, two (2), bathroom home, with a kitchen/dining area, living room, and attached garage. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (6) current census (4). LPA was accompanied by Facility Administrator Rowena Formeloza, to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected residents bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be at 116.9 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside medication cabinet inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of Residents in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023

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: IRA CARE	FACILITY NUMBER: 361881288
	VISIT DATE: 07/29/2023

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Record Review: LPA reviewed four (4) residents files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Rowena Formeloza .

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023

LIC809 (FAS) - (06/04)

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