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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530012
Report Date: 01/24/2025
Date Signed: 01/24/2025 04:57:16 PM

Document Has Been Signed on 01/24/2025 04:57 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HELPING HEARTS ACACIAFACILITY NUMBER:
365530012
ADMINISTRATOR/
DIRECTOR:		HAMPTON, CHRISTALFACILITY TYPE:
772
ADDRESS:1767 N ACACIA AVETELEPHONE:
(909) 292-8997
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 5DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Lori Secord, Program Director, Hector Andrade, Program Director TraineeTIME VISIT/
INSPECTION COMPLETED:
04:58 PM
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Licensing Program Analyst, LaVette Farlow, (LPA) arrived at the Helping Hearts: Acacia Social Rehabilitation Facility, to conduct the Annual Inspection. LPA was granted entry by Program Manager, Lori Secord. LPA introduced self to the, Program Manager, Lori Secord and stated the purpose of the visit. Lori escort LPA to her office and 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, of 73 degrees. 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 bathrooms, and kitchen. Water temperature ranged between 114.3, 119.8, and 118.5 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 two fully charged fire extinguishers throughout the facility; last inspected January 2025.
Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HELPING HEARTS ACACIA
FACILITY NUMBER: 365530012
VISIT DATE: 01/24/2025
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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 3 freezers. LPA observed a variety of food items available to residents in care. Items such as frozen meals, beverages, eggs, vegetables, milk, and meats. Food Menu observed posted near the kitchen.
Care & Supervision: During today's visit, it was reported the current census is five, (5), with four, (4) staff members present including Program Manager and Program Manager Trainee; 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. LPA observed that the facility Emergency Disaster Plan has not been reviewed since May 22, 2023. A technical violation issued.
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. One technical violation issued. Exit interview conducted, this report was reviewed, discussed and copy provided to Program Manager, Lori Secord and Hector Andrade, Program Manager Trainee.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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