<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530060
Report Date: 11/18/2022
Date Signed: 11/18/2022 03:03:54 PM


Document Has Been Signed on 11/18/2022 03:03 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:SELENA SENIOR HOME LLCFACILITY NUMBER:
365530060
ADMINISTRATOR:HUSSEIN, SHADENFACILITY TYPE:
740
ADDRESS:9713 EUGENIA AVETELEPHONE:
(205) 777-9144
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:6CENSUS: 0DATE:
11/18/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shaden Hussein, Fadi SuleimanTIME COMPLETED:
03:30 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 (LPA) Amy Goldenberg conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate a residential care facility for the elderly Facility was submitted to the Central Applications Unit (CAU) in September 2022 for a total capacity of 6 ambulatory residents. Fire Clearance was granted 10/31/2022/. LPA Goldenberg observed the following:

Structure: Facility was a single story house with three (5) bedrooms, Three full bathrooms and one 1/2 bathroom, living room, dining area, and kitchen area, three car garage.

Heating/Cooling System: Central heating and air conditioning systems.

Bedrooms: Each resident bedroom will accommodate ambulatory only clients. All bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by LPA at 107 F.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
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 2


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: SELENA SENIOR HOME LLC
FACILITY NUMBER: 365530060
VISIT DATE: 11/18/2022
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
26
27
28
29
30
31
32
Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.

Linens and Hygiene Supplies: An adequate supply of linens was available.

Yards/Outside: The back was completed was a patio with adequate covered area for providing shade. There were no obstructions. There were no bodies of water observed anywhere on the property.

Garage: Laundry area with washer and dryer were located just inside the home prior to the garage exit garage. Laundry detergents and cleaning solutions were secured behind a locked cabinet door. Garage was organized and free of obstructions. There was a recreational leisure area set up for staff and client use.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster and personal rights are posted.

General items: LPA observed a facility phone and it was verified to be operational.

LPA reviewed COMPONENT III with the applicant during this Pre Licensing Inspection.

This facility physical plant is prepared for licensure at this time. This report is being reviewed with the applicant and a copy is being provided.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2