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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530071
Report Date: 02/03/2023
Date Signed: 02/03/2023 02:36:12 PM


Document Has Been Signed on 02/03/2023 02:36 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:CTR HOME CARE LLCFACILITY NUMBER:
365530071
ADMINISTRATOR:PEREZ, APOLINARIOFACILITY TYPE:
740
ADDRESS:11490 RICHMONT ROADTELEPHONE:
(909) 894-3852
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 5DATE:
02/03/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator Apolinario PerezTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Victoria Chitgian conducted an announced visit to complete a pre-licensing inspection and component III. LPA met with Administrator Apolinario Perez. The application is for a Residential Care Facility for the Elderly (RCFE) change of ownership. The approved fire clearance granted six (6) non-ambulatory residents. Currently residing at the facility are five(5) residents.

The interior and exterior was toured of the pending facility. Overall, the pending facility is clean and in good condition. LPA observed all bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, showers have grab bars and non-skid mats. The hot water temperature in the kitchen was measured at 117 degrees Fahrenheit. LPA observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer temperatures are maintained at appropriate temperatures. All appliances are clean and operating properly. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present including an approved First Aid Manual.

LPA observed an adequate supply of recreation and leisure items and activities. The backyard is completely enclosed with functioning gate to exit to front yard. Outdoor space is suitable for resident use that includes a covered patio with a table and chairs. LPA observed the fire extinguishers to be recently serviced and completely charged. Smoke alarms and carbon monoxide detectors are present and functional. Medications will be centrally stored and secured in a locked cabinet. All hazardous materials such as, cleaning, and disinfecting supplies, knives and other sharps are locked and inaccessible to residents. All required forms are posted in a common area.

Pre-Licensing Inspection and Comp III has been completed and the facility has no deficiencies or needed corrections.
An exit interview was conducted where this report was discussed and provided to Administrator Apolinario Perez.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Victoria ChitgianTELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
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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