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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530027
Report Date: 07/14/2022
Date Signed: 07/14/2022 04:23:11 PM

Document Has Been Signed on 07/14/2022 04:23 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:VALLEY HOME IIFACILITY NUMBER:
365530027
ADMINISTRATOR:MIGUEL, CRISELDAFACILITY TYPE:
735
ADDRESS:1256 MORRISON DRIVETELEPHONE:
(909) 798-1650
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 4CENSUS: 3DATE:
07/14/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Applicant/Administrator Artemio DirigeTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Melody Brown conducted an announced visit to the facility 07/14/2022 to conduct a Pre-licensing inspection for the above facility. LPA met with Applicant/Administrator Artemio Dirige. An initial application for change of ownership to operate for an Adult Residential Care Facility was submitted to the Central Applications Bureau (CAB) on 06/17/2022 for a total capacity of four (4). The Fire Safety Inspection was approved on 06/27/2022 for two (2) Non-Ambulatory Adult Clients and two (2) Ambulatory Adult Clients. LPA Brown observed the following:
Structure:
Facility was a one-story house with three (3) resident bedrooms, one (1) staff bedroom and two (2) resident/staff bathroom, living room, dining area and kitchen. There was an attached two (2) car garage in the left side of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located outside, at the left side of the house to control the entire house.
Bedrooms:
Each resident bedroom #2, and bedroom #3, will accommodate ambulatory clients, bedroom #4 will accommodate two (2) non-ambulatory clients and bedroom #1 will be the staff bedroom. Three (3) client bedrooms and one (1) staff room were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
The (2) resident/staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. At 03:00 PM, LPA Brown tested the water temperatures in the client bathrooms. LPA Brown verified water temperature was measured at 107 degrees Fahrenheit.

(CONTINUED ON LIC 809C)

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: VALLEY HOME II
FACILITY NUMBER: 365530027
VISIT DATE: 07/14/2022
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Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA Brown observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer and laundry detergents and cleaning supplies were observed locked away from clients.
Living/Family room:
There was a living/family room with adequate seating for all clients and a working TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.
Yards/Outside:
One (1) Patio furniture for outdoor seating observed. Self-latching handle on the right side of the house that leads into the backyard. There is a gate/door on the left side with exit into the front of the house. All outdoor pathways were not free of obstructions. Two (2) broken wheelchairs and broken gutters were observed.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the living room and entry hallway. There’s no Let-Us-No poster and Labor Laws observed and no Ombudsman Poster.
General items:
One (1) fire extinguisher were charged and located in the kitchen. Seven (7) dual smoke alarms/monoxide and were tested and were observed to be in working order. Client records were stored in a locked filing cabinet in the staff room. First Aid kit with missing required component, and locked area for medication storage was observed. LPA Brown observed a facility phone and it’s operational, cable and internet service available as well. There is enough Emergency water supply observed and the required 72-hour emergency food supply but no Client Emergency Bag Pack Available for each client. Component III was completed on this day as well.

Additionally, LPA observed facility to have required single entry point for COVID screening, upon entering facility. LPA Brown observed required COVID signages but not throughout the facility, No Visitation Vaccination Requirement Log and there are soap and disposable towels in bathrooms for washing hands. LPA Brown observed activities for the clients such as books, magazines, games and Monthly Activity Calendar posted.

(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: VALLEY HOME II
FACILITY NUMBER: 365530027
VISIT DATE: 07/14/2022
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Pre-Licensing is incomplete and the following deficiencies to be resolved by 08//01/2022 at 1:30 PM:

Obtain and post Let-Us-No Poster
Obtain and post an Ombudsman poster
Obtain and post Labor Laws
Print and Post Covid-19 Signages in the common areas of the facility
Visitor Vaccination Verification Log
Pull-out two (2) broken wheelchairs at the backyard
Pull-out broken gutter at the backyard
Dispose recyclable empty bottles in the garage and boxes
Obtain one (1) Stand up Light for bedroom # 4

A follow up Pre-Licensure LIC809 will be generated upon resolution of deficiencies.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
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