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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530173
Report Date: 01/05/2024
Date Signed: 01/05/2024 03:09:43 PM

Document Has Been Signed on 01/05/2024 03:09 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:A HOMEY PLACEFACILITY NUMBER:
365530173
ADMINISTRATOR:DAMASO, MARIA TERESAFACILITY TYPE:
735
ADDRESS:17416 EUCALYPTUS STREETTELEPHONE:
(626) 319-8628
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 6CENSUS: 0DATE:
01/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Teresa DamasoTIME COMPLETED:
03:11 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an announced visit to complete a pre-licensing inspection for a change of facility type application. LPA Bueno identified herself to licensees Teresa and Kish Damaso and informed them of the purpose of the visit.

The facility has a Residential Care Facility for the Elderly (RCFE) license and is currently applying for licensed Adult Residential Facility. The facility has been granted a fire clearance on 11/06/2023 by the Fontana Office for a total capacity of 6 clients, 5 of which may be nonambulatory.

LPA Bueno and Licensees toured the interior and exterior of the facility. The facility has five client bedrooms, three and a half bathrooms, kitchen, a living/sitting room, dining and activity area, and backyard. The facility has no bodies of water. A covered patio allows for ample seating and recreational outdoor activities. LPA observed that side gate was unlocked and free of obstruction. The facility has a working telephone. LPA observed charged fire extinguishers while combination smoke and carbon monoxide alarms were tested and found to be in working order. The facility keeps a complete first aid kit and manual. A locked centralized storage area for medications and client and staff files was observed.

The following were observed of the physical plant:
Client Bedrooms: LPA observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting.
Client Bathrooms: LPA observed all bathrooms and fixtures are kept in sanitary conditions. LPA observed night lights were maintained in the hallways near bathrooms.
Dining Area and Kitchen: LPA inspected the kitchen and found dishes, glasses, and utensils were in good working order. The dining table, kitchen countertop, appliances, and floors were free of debris. Cleaning supplies are secured and sharps are locked separately from other supplies. LPA observed appropriate food provisions. Sample menu is available for review.
Activity Area and Living Room: LPA observed adequate seating in the common areas. The facility had a supply of activities and reading materials for individuals served. Planned weekly activities was reviewed by.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: A HOMEY PLACE
FACILITY NUMBER: 365530173
VISIT DATE: 01/05/2024
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LPA Bueno observed that the physical plant is clean, in good repair, and appear to be hazard-free during today's visit. LPA completed COMP III with Licensees Teresa and Kish Damaso at the conclusion of the inspection.

The pre-licensing inspection is complete and this facility has no corrections to be made. Licensees have satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy was provided to Teresa Damaso at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC809 (FAS) - (06/04)
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