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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530002
Report Date: 04/22/2022
Date Signed: 04/22/2022 11:15:40 AM

Document Has Been Signed on 04/22/2022 11:15 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:COROMINA ADULT HOMEFACILITY NUMBER:
365530002
ADMINISTRATOR:COROMINA, DENISEFACILITY TYPE:
735
ADDRESS:20223 PIPPIN COURTTELEPHONE:
(760) 508-4798
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 2CENSUS: 0DATE:
04/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Denise CorominaTIME COMPLETED:
11:30 AM
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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/Administrator, Denise Coromina. The application is for a Adult Residential Facility for two (2) ambulatory only clients.
A tour of the pending facility was conducted inside and out. Overall, the pending facility is clean and of new construction. The back yard had a hot tub that is covered, locked and inaccessible to clients. There no 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, Ms. Coromina states she will move all recreation and leisure items over once they clients move from their current residence. 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.
Ms. Coromina 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 Ms. Coromina.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2022
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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