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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530146
Report Date: 11/06/2023
Date Signed: 11/06/2023 02:42:23 PM


Document Has Been Signed on 11/06/2023 02:42 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:CASSANDRA'S CARE HOMEFACILITY NUMBER:
365530146
ADMINISTRATOR:ELLISON, CASSANDRAFACILITY TYPE:
740
ADDRESS:10175 GOLDEN YARROW LANETELEPHONE:
(909) 664-7137
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY:6CENSUS: 0DATE:
11/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Cassandra Ellison, Administrator/LicenseeTIME COMPLETED:
02:45 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at Cassandra's Care Home for a scheduled visit to conduct the Pre-Licensing Inspection. LPA approached the door, introduced self and stated purpose of the visit. LPA was greeted and granted entry by Cassandra Ellison, Administrator/Licensee. LPA was provided a space to set up and work, then provided a tour of the facility inside and out. LPA observed the following:
Application: The application is for Residential Care Facility for the Elderly, (RCFE) submitted on 4/10/23. Fire clearance has been granted for five, (5) non-ambulatory residents and one, (1) bedridden resident. Fire clearance and inspection completed and approved on 7/10/23.
Buildings and Grounds: The facility is a 1 level residential home. Facility is comprised of 5 bedrooms (4 resident rooms, 1 office), 2 bathrooms, kitchen, dining room, living room, attached garage and backyard. LPA observed the following signage throughout the facility: LET-US-KNOW, resident rights, resident council, labor laws, employee rights, visiting hours, evacuation/disaster plans, and infection control. Extra linens are kept in a hallway closet. Another hallway closet is designated to house cleaning supplies and tools. This hallway closet can also be secured. Facility in regulatory temperatures.
Resident Rooms - each room included mattresses, mattress covers, bed linens, storage for clothing and belongings, intact windows and screens and sufficient lighting. Each room also included a floor plan with the evacuation route highlighted. 2 resident rooms contain a doorway entry into the facility's backyard. Both doorways included a cement ramp and railing for additional support and added safety.
Bathrooms - There are 2 bathrooms, LPA observed each bathroom equipped with railing inside the showers and non-slip grip mats on the floor. Bathrooms also included a walk in shower and raised toilet seats. One of the bedrooms' includes an attached bathroom.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
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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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: CASSANDRA'S CARE HOME
FACILITY NUMBER: 365530146
VISIT DATE: 11/06/2023
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Food Service/Kitchen: LPA observed the facility kitchen. Appliances observed to be functional and in good repair. Silverware, dishes and cups stored in adequate amounts for the number approved residents. The designated area for sharps and additional cleaning supplies are secure cabinets and drawers. The kitchen pantry is also houses the facility's first aid kits. The water temperature was tested and measured between 110-120 within regulatory limits.
Living Room/Dining Area- included adequate seating, and a television. Activities such as board games, connect four, checkers/chess, bingo observed in the dining room; accessible for resident's use. The facility maintains an internet connection and working landline phone for residents.
Storage and Supplies: Facility Records, Staff/Resident files are designated to be stored in the facility office; which is also secure.
Backyard: included adequate seating, shade and space for activities. During the walk through, LPA observed that the facility formerly had a pool, has filled it in. No pools or body of waters on facility grounds. The backyard also contains a firepit, but the gas line has been removed, per Administrator.
Exterior pathways were clear and unobstructed. Administrator and Licensee report there are no weapons or ammunition kept in the facility. LPA walked through the facility garage. The facility's washer and dryer is housed in the garage. Garage door is secure. The garage contained securable cabinets for laundry detergent/bleach.
Overall, the facility is clean, in good repair, and operating in safe conditions. Pathways interior and exterior free of obstructions. LPA observed combination smoke/fire and carbon monoxide alarms throughout the facility. 2 fully charged fire extinguishers - purchased October 2023.

No deficiencies were observed during inspection. LPA will inform the Centralized Applications Bureau the home is ready to be licensed. An exit interview was conducted. This report was reviewed, discussed then provided to Cassandra Ellison.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC809 (FAS) - (06/04)
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