<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530002
Report Date: 05/10/2023
Date Signed: 05/10/2023 02:45:29 PM

Document Has Been Signed on 05/10/2023 02:45 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: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: 2DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Denise Coromina-LicenseeTIME COMPLETED:
02:50 PM
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
On 05/10/23 at 12:45 PM, Licensing Program Analyst (LPA) MIchelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Licensee, Denise Coromina, and introduced self and stated purpose of the visit. LPA was informed that there are currently 2 residents in care who are in their bedroom.

The facility has 2 resident bedrooms, 2 bathrooms, exercise room, 2 offices, front room, a kitchen, dining area, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of facility and review of records.

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 of 72 degrees farenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 114.4 degrees farenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and one charged fire extinguisher. Posters such as; the personal rights and disaster plans were posted in the office. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets inaccessible to residents. There was a designated storage space for resident/staff files. Medications and first aid kit were observed in secure cabinets and inaccessible to residents in the living room. The facility had emergency kits in the garage for residents in care. 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. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: COROMINA ADULT HOME
FACILITY NUMBER: 365530002
VISIT DATE: 05/10/2023
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
26
27
28
29
30
31
32
Yards/Outside: One shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard. One hot tub with cover and lock meeting regulations. All outdoor pathways were free of obstructions.
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. Licensee and spouse reside in the home.
Record Review: LPA reviewed 2 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed Licensee file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I funds were counted at random and matched with the ledger. Medications were audited at random and appeared to be dispensed appropriately by staff. The facility last conducted a disaster drill in March 21, 2023.

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 and LIC809C were discussed and copies were provided to the Licensee, Denise Coromina.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2