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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530012
Report Date: 01/09/2024
Date Signed: 01/09/2024 01:39:23 PM

Document Has Been Signed on 01/09/2024 01:39 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:HELPING HEARTS ACACIAFACILITY NUMBER:
365530012
ADMINISTRATOR:HAMPTON, CHRISTALFACILITY TYPE:
772
ADDRESS:1767 N ACACIA AVETELEPHONE:
(909) 292-8997
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 6DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Lori Secord, Program ManagerTIME COMPLETED:
01:45 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Helping Hearts: Acacia Social Rehabilitation Facility, to conduct the Annual Inspection. LPA introduced self to staff, who notified Program Manager, Lori Secord of LPA's visit. LPA was granted entry, provided a space to work and a walk through of the facility.

LPA was accompanied by Program Manager, Lori Secord to conduct a tour of the facility, inside and outside, and observed the following:
Facility: The Facility is licensed for six (6) ambulatory adults, ages 18 -59.
Physical Plant: LPA observed the facility was maintain within a reasonable temperature. Interior pathways were free of clutter. Resident rooms contained beds with appropriate linens, adequate amounts of storage space, night stands, sufficient lighting, seating and privacy. Bathrooms contained operational appliances adequate amount of hand hygiene and paper supplies. Also, non-slip grip materials for safety. Extra hygiene and paper supplies are securely maintained. LPA measured the water temperature in the facility's bathroom. Water temperature ranged between 109 - 118 degrees Fahrenheit. Sufficient lighting is provided throughout the facility with various lamps and night lights. The facility contained smoke/fire/carbon monoxide alarms. Program Manager reports that Earthquake and Fire Drills are conducted on a monthly basis. LPA observed three fully charged fire extinguishers throughout the facility; last inspected March 2023.

Food Service: During the walk through of the kitchen, LPA observed the facility's non-perishable and perishable food supply. Canned and dry goods in good standing. Perishable foods are maintained within 2 refrigerators and 2 freezers. LPA observed a variety of food items available to residents in care. Items such as frozen meals, beverages, eggs, vegetables, milk, meats and leftovers. Food Menu observed posted near the kitchen.
Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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: HELPING HEARTS ACACIA
FACILITY NUMBER: 365530012
VISIT DATE: 01/09/2024
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Food Service: During the walk through of the kitchen, LPA observed the facility's non-perishable and perishable food supply. Canned and dry goods in good standing. Perishable foods are maintained within 2 refrigerators and 2 freezers. LPA observed a variety of food items available to residents in care. Items such as frozen meals, beverages, eggs, vegetables, milk, meats and leftovers. Food Menu observed posted near the kitchen.
Care & Supervision: During today's visit, it was reported the current census is six, (6), with four, (4) staff members present including Program Manager; which is adequate for the number of residents in care.
Record Review and Resident/Staff Files: LPA reviewed records for updated physician reports and Needs and Services Plans. LPA verified resident records contained required documents. LPA reviewed staff files;
and confirmed that staff records reflect current CPR/First Aid Certification and Criminal Record Clearance.
Administration: Facility Sketch, Disaster Plan, Emergency Contact Information & Procedures, Fire Inspection letter, Ombudsman poster, Resident Rights, House Rules, Infection Control, and facility license are posted in a prominent place in the facility.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and securely maintained.

Based on observations, record reviews and interviews, no deficiencies were cited during this inspection. Exit interview conducted, this report was reviewed, discussed and copy provided to Program Manager, Lori Secord.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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