365530162-10-11-2023-56-AS-MBRN-CWHT2Y-20231011142130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530162
Report Date: 10/11/2023
Date Signed: 10/11/2023 02:21:41 PM

Document Has Been Signed on 10/11/2023 02:21 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	FOOTHILL SERENITY LIVING		FACILITY NUMBER:	365530162
ADMINISTRATOR:	GUEVARRA, MARYDES		FACILITY TYPE:	735
ADDRESS:	8024 REDWOOD AVE		TELEPHONE:	(909) 371-3967
CITY:	FONTANA	STATE: CA	ZIP CODE:	92336
CAPACITY: 32		CENSUS: 28	DATE:	10/11/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Administrator/Applicant Marydes Guevarra		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/11/2023 at 09:05 AM, Licensing Program Analysts (LPAs) Melody Brown and Bianca Wolcott conducted an announced visit to complete the Prelicensing Inspection. LPAs met with Administrator/Applicant Marydes Guevarra. This facility was previously licensed as Angels Assisted Living Redwood (366426788) and is undergoing a change of ownership. The pending application is for a capacity of thirty-two (32) ambulatory clients in an Adult Residential Facility (ARF). Fire clearance was granted by Fontana Fire Department on 09/07/2023 for fifteen thirty-two (32) ambulatory clients. The facility has sixteen (16) client bedrooms, one (1) staff room and ten (10) bathrooms. There are sixteen (16) client bedrooms, one (1) staff room, one (1) office/medication room, a kitchen, a lobby area,a dining area, a recreational room, a laundry room, and a backyard. LPAs Brown and Wolcott toured the interior and exterior areas of the facility. The following were inspected: Client Bedrooms: All bedrooms have the required bedding and furniture, such as clean mattresses/linen, nightstands, dressers, chairs, and lighting. Client Bathrooms: The bathroom appliances were operating in safe and sanitary condition. The water temperature was measured at 117 degrees F. Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use upon request. Kitchen appliances and countertop were free of debris and in good repair. Knives and sharps were safely secured and locked. The refrigerator was measured at 38 degrees F and the freezer was measured at 0 degrees F. The facility has a posted meal schedule. There were seven (7) days non-perishable food inside the pantry and two (2) days perishable food inside the refrigerator/freezer. *CONTINUED ON LIC 809-C*

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: FOOTHILL SERENITY LIVING	FACILITY NUMBER: 365530162
	VISIT DATE: 10/11/2023

NARRATIVE

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***CONTINUED FROM LIC 809C***

Staff Office/Medication Room: The medications were safely locked and secured. There is a safely locked and secured filing cabinet where clients and staff files are stored.

Common Sitting Areas: There is adequate seating in the common areas. The facility has a supply of activities for the clients.

Laundry Room: The chemicals and laundry soap were safely locked in this room.

Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies were available for each client.

Backyard: There are no bodies of water in the backyard. All passageways were free from obstruction.

Fire extinguisher, smoke detectors,carbon monoxide, firearms: There were 11 charged fire extinguishers in the facility. LPAs Brown and Wolcott observed operating eighteen (18) smoke detectors and eighteen (18) carbon monoxide alarms. The home does not have any firearms and ammunition.

Postings: LPAs Brown and Wolcott observed required postings including the visitation policies, emergency/disaster plans, complaint procedures, labor laws and personal rights.

First aid and telephone: The facility was equipped with a complete first aid kit, first Aid book and emergency kits. The facility has a working land line and telephone for clients’ use.

***CONTINUED ON LIC 809-C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: FOOTHILL SERENITY LIVING	FACILITY NUMBER: 365530162
	VISIT DATE: 10/11/2023

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***CONTINUED FROM LIC 809C
LPAs Brown and Wolcott observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPAs Brown and Wolcott have determined that the facility meets the operational requirements for licensure. The Prelicensing inspection is complete, and the facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations. Based on the observations and evaluation of the facility this date, the facility is ready for licensure.

The required Comp III presentation was completed.

Licensee will be notified once facility is licensed.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC809 (FAS) - (06/04)

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