365530007-6-14-2023-56-AS-ACON-CSSPR2-20230614113203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530007
Report Date: 06/14/2023
Date Signed: 06/14/2023 11:32:07 AM

Document Has Been Signed on 06/14/2023 11:32 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:	TRES MARIAS HOME CARE LLC		FACILITY NUMBER:	365530007
ADMINISTRATOR:	ALORO, MARIA NENITA N.		FACILITY TYPE:	740
ADDRESS:	749 W WINCHESTER DR.		TELEPHONE:	(909) 874-4712
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	6	CENSUS: 5	DATE:	06/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Maria Aloro, Adminsitrator		TIME COMPLETED:	12:00 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	Licensing Program Analyst, Amber Coleman (LPA) arrived at the Tres Marias Home Care Facility unannounced to conduct an Annual Inspection. LPA introduced self and stated the purpose of the visit. LPA signed in and was provided a space to work. The facility has 3 resident bedrooms, 1 staff room, 2 bathrooms, a kitchen, dining area, living room, attached garage, and backyard. LPA conducted 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 resident bedrooms; they are each equipped with required furniture such as: mattresses, night stands, adequate storage space, and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean. Appliances were operating appropriately and included adequate paper and hand hygiene products. Resident's hygiene materials were located in a secure cabinet under the sink. LPA tested the water temperature of the kitchen faucet, which ranged at 105 to 114 degrees F. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Posters such as; the personal rights, infection control and disaster plans were posted in common areas throughout the facility. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents. The designated storage space for resident/staff files is a secure hallway closet. Medications were locked and inaccessible to residents. The facility had emergency and first aid kits readily available for residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents. Please see LIC809-C

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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: TRES MARIAS HOME CARE LLC	FACILITY NUMBER: 365530007
	VISIT DATE: 06/14/2023

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Food Service: Non-perishable and perishable food supply is sufficient for number of clients residing in the facility. Facility has a variety of food available for residents; according to the monthly food menu posted on the facility refrigerator. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed during the visit.
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.
Record Review: LPA reviewed 3 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 3 staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members.

Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A Technical Violation is being issued due to a locked side gate, which was corrected during the visit. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

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