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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530054
Report Date: 02/02/2024
Date Signed: 02/02/2024 03:08:53 PM

Document Has Been Signed on 02/02/2024 03:08 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:C AND T HOME CAREFACILITY NUMBER:
365530054
ADMINISTRATOR:GARCIA, CRISZELIE D.FACILITY TYPE:
735
ADDRESS:8515 RAMONA AVE.TELEPHONE:
(909) 244-9610
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY: 6CENSUS: 4DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Criszelie Garcia, Adminstrator TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced annual required visit. LPA was greeted and granted entry to the facility by Administrator Garcia. LPA explained the nature of today's visit. This home is designated as a level 2 home by IRC.

LPA accompanied with MS Garcia, conducted a general overall inspection, which included, but was not limited to the following:

Physical Plant: The facility was not operating over capacity or beyond any conditions and limitations on the license. There are no pools or other bodies of water located on the premises. There are no ammunition or firearms kept in the home. Facility is being maintained at a comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Hot water temperature was measured at 110.1 degrees Fahrenheit in all resident bathrooms. There are grab bars for each toilet, bathtub and shower used by residents. Smoke detector and Carbon Monoxide devices were tested and found to be in working.

Food Service: There is a minimum of one week supply of nonperishable foods and 2 days of perishable foods.

Care and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: C AND T HOME CARE
FACILITY NUMBER: 365530054
VISIT DATE: 02/02/2024
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Record Review: LPA requested and reviewed four (4) resident and two (2) staff files. LPA reviewed staff files for current CPR/1st aide certificates, TB results, and required training's. LPA reviewed client files for admissions agreement, physician report, and IPP. Administrator certificate is current.

Administration: The last fire drill and last disaster drill was not yet conducted as placement of only client was 12/15/2023. LPA did not observe any excluded individuals on the premises at time of visit. The Administrator appears to be on the premises a sufficient number of hours to manage and oversee the business operation.

Medical Related Services: Prescriptions and non-prescription PRN medications contain a signed and dated written order from a physician. Medications are centrally locked in the staff office and inaccessible to residents in care. Medications are being administered as prescribed by physician's directions.

No deficiencies cited. An exit interview was conducted where this report was provided and discussed with MS Garcia.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC809 (FAS) - (06/04)
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