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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530086
Report Date: 10/10/2024
Date Signed: 10/10/2024 10:23:07 AM

Document Has Been Signed on 10/10/2024 10:23 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HIS HOUSEFACILITY NUMBER:
365530086
ADMINISTRATOR/
DIRECTOR:		BEATRICE, DANIELLEFACILITY TYPE:
772
ADDRESS:1354 CARLOS PLACETELEPHONE:
(909) 519-0767
CITY:ONTARIOSTATE: CAZIP CODE:
91764
CAPACITY: 6CENSUS: 0DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Facility Administrator Danielle BeatriceTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPAs) Beena Singh and Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs met with Facility Administrator Danielle Beatrice. The facility is Social Rehabilitation Facility (SRF). There are currently no clients in care. The Administrator Danielle Beatrice accompanied LPA on a tour of the inside and outside of the facility. The home is a three (3) bedroom, two (2) bathroom home with a living room, dining room, kitchen, and attached garage. LPA was accompanied by Facility Administrator Danielle Beatrice, to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA Beena Singh inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Beena Singh observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 112 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. There was a designated space for client/staff files. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present. There are no pools, bodies of water, firearms, or ammunition The backyard is completely enclosed with functioning gate to exit to front yard. The outdoor space is suitable for client use.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HIS HOUSE
FACILITY NUMBER: 365530086
VISIT DATE: 10/10/2024
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Record Review: LPA Beena Singh reviewed (3) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. There are no clients so no clients files were reviewed at this time.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Danielle Beatrice.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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