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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530160
Report Date: 03/15/2024
Date Signed: 03/15/2024 09:49:09 AM

Document Has Been Signed on 03/15/2024 09:49 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:CANARY CARE HOMEFACILITY NUMBER:
365530160
ADMINISTRATOR:DINEROS, OLIVERFACILITY TYPE:
735
ADDRESS:7198 WAKE CTTELEPHONE:
(909) 319-5962
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 0DATE:
03/15/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Oliver DinerosTIME COMPLETED:
10:00 AM
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Licensing Program Analysts (LPA) Mary Rico conducted an announced Pre-Licensing visit to the facility. LPA met with Facility Administrator Oliver Dineros. The pending application is for an Adult Residential Facility. The facility has been granted a fire clearance for a total capacity of four (4) ambulatory on 1/24/2024. The Administrator accompanied LPA on a tour of the inside and outside of the facility. The home is a four (4) bedroom and two and half bathroom and with a living room, dining room, kitchen, loft 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, night stand, dresser, and chair. All bedrooms have adequate lighting for clients 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 bathroom to be at 115 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. Medications are stored and secured in a locked cabinet inaccessible to clients. 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.

An exit interview was conducted, and a copy of this report was provided to Administrator Oliver Dineros.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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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