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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530082
Report Date: 06/27/2023
Date Signed: 06/27/2023 10:53:26 AM

Document Has Been Signed on 06/27/2023 10:53 AM - 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:ALOHA DUMOND HOMEFACILITY NUMBER:
365530082
ADMINISTRATOR:TALLA, OMARFACILITY TYPE:
735
ADDRESS:7888 DUMOND DRTELEPHONE:
(626) 675-7256
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 3DATE:
06/27/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Omar Talla & Maria, Administrators/LicenseesTIME COMPLETED:
10:50 AM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Aloha Dumond Home, Adult Residential Facility to conduct a Pre-Licensing Inspection for changing licensees. LPA introduced self and stated purpose of the visit. LPA was greeted and granted entry by both Maria and Omar Talla. LPA was provided a space to work, then given a walk through of the facility. There are 3 residents in care at this time. At the time of the visit, two, (2) residents were at the prospective Adult Programs, while the last resident was on his way out to his Adult Program.

Application: The application is for an Adult Residential Facility (ARF) submitted on 3/23/23. Fire clearance was approved for four (4) Ambulatory Residents on 12/15/22.

Buildings and Grounds: The facility is comprised of Kitchen, two, (2) common areas, a dining room, three (3) bedrooms, 2 bathrooms, a laundry room, backyard and attached garage. The exterior pathways of the facility were free of obstructions. The backyard area included 2 shaded seating areas and garden for the residents. Backyard area also has sufficient room for activities and leisure. There are no pools or other bodies of water observed on grounds.
Smoke and Carbon Monoxide detectors were tested and observed operational. (2) Fire Extinguishers located in the kitchen and hallway- last inspected March 2023. Interior passageways were clear and free of obstruction. Administrators report there are no weapons stored in the facility. Bedrooms all contain regulated furnishings, privacy and personal touches. All furnishings observed to be clean and in good repair.
The dining and living room areas are free of clutter and in good repair.
The water temperature was tested and measured at 98 to 100 degrees Fahrenheit, which is within regulatory limits. Activity materials such as books, board games, video games and puzzles were available for resident use. The washing machine and dryer were in operation during visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALOHA DUMOND HOME
FACILITY NUMBER: 365530082
VISIT DATE: 06/27/2023
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Storage and Supplies: Medications are stored in secure file cabinets in a common area. Staff and Resident files are also kept inaccessible in separate file cabinet. The First Aid kits were observed to be readily available to those who may need it. Cleaning supplies, sharp objects, and tools were observed in secure cabinets throughout kitchen, garage and bathrooms. Linens, personal hygiene supplies, and hygiene equipment are all in good repair and sufficient for approved census. Bathrooms were observed to have non-slip bath mats a and adequate paper supplies. LPA observed that PPE is also kept throughout the facility. PPE such as gloves, masks, and disinfectant wipes.
Food Service: Utensils and dishware are sufficient for the requested capacity. The facility keeps two (2) refrigerators and a deep freezer to store food for both residents and staff. LPA observed a variety of food and fresh food made available to residents. Milk, eggs, cheese, fruits, waters and juice was observed in the kitchen refrigerator The facility also produces a weekly food menu for its residents.

Forms: The following forms were observed posted throughout the facility: Emergency Disaster/ Evacuation Plan (LIC 610D), Emergency contact information, Personal Rights, Facility Sketch (LIC 999), Labor Laws, Infection Control, Staff Schedule, Food Menu, Appointment Calendars, and Administrator Certificates.

During the walk through, LPA observed that a resident room near the garage and laundry room is missing window screen. Administrator reported it is to be fixed by Friday - 6/30/23. LPA also observed that the living room area ceiling was pealing. Administrator reported that the A/C was serviced and resulted in a leak causing the paint to peel. It was reported that this is due to be fixed within the week. The facility will be ready to be licensed when these tasks are completed.

An exit interview was conducted where this report was reviewed, discussed and then provided to Administrator/Licensee, Maria Talla.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC809 (FAS) - (06/04)
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