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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530100
Report Date: 08/24/2023
Date Signed: 08/24/2023 02:30:37 PM

Document Has Been Signed on 08/24/2023 02:30 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:AUTUMN BLISS HOMEFACILITY NUMBER:
365530100
ADMINISTRATOR:STINSON, NICOLEFACILITY TYPE:
740
ADDRESS:17885 ATHOL STTELEPHONE:
(909) 452-7417
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: 0DATE:
08/24/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Nicole StinsonTIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPA) Paola Guerrero conducted an announced pre-licensing visit to facility. LPA met with Facility Administrator Nicole Stinson. The pending application is for a Residential Care Facility for Elderly (RCFE). There are currently no residents in care. The Administrator accompanied LPA on a tour of the inside and outside of the facility. The home is a four (4) bedroom, two (2) bathroom home with a living room, dining room, kitchen, and attached garage. The physical plant, in general, was in good repair. The buildings and grounds are free from hazards. The indoor and outdoor passageways are free of obstruction. There are no pools, bodies of water, firearms, or ammunition. All bedrooms are furnished with a bed, nightstand, dresser, and chair. All bedrooms have adequate lighting for resident use. Bathroom's toilet, shower and tubs are in good repair and have non-skid mats. LPA measured and observed the water temperatures in the bathrooms to be at 108 degrees F. LPA observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer are maintained at appropriate temperatures. All appliances are clean and operating properly. Dishes, glasses, and utensils were in good condition. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present. The backyard is completely enclosed with functioning gate to exit to front yard. The outdoor space is suitable for client use. LPA observed fully charged fire extinguisher present in the facility. Smoke alarms and carbon monoxide are present and functional. Facility has a designated area where medications will be stored in a locked closet. The facility had a designated area for staff and client records. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There is adequate seating in the common areas. Facility had a supply of activities for the clients.

Pre-licensing inspection is complete, and no corrections are needed to be made. The Comp III presentation was completed during today's visit.

An exit interview was conducted, and a copy of this report was provided to Facility Administrator Nicole Stinson.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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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