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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530215
Report Date: 09/25/2024
Date Signed: 09/25/2024 11:24:25 AM

Document Has Been Signed on 09/25/2024 11:24 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DE RAMOS HOME-ONTARIOFACILITY NUMBER:
365530215
ADMINISTRATOR/
DIRECTOR:		DE RAMOS, ISABELITAFACILITY TYPE:
735
ADDRESS:1125 W J STREETTELEPHONE:
(951) 818-1140
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 4CENSUS: 3DATE:
09/25/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator Isabelita De RamosTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 09/25/2024, Licensing Program Analysts (LPAs) Raquel Hernandez and Melody Brown conducted an announced visit to complete the Prelicensing inspection. LPAs met with Administrator Isabelita De Ramos
This facility was previously licensed as LMB Care Home (366408320) and is undergoing a change of ownership. The pending application is for a capacity of four (4) ambulatory clients in a Adult Residential Facility (ARF). Fire clearance was granted by Ontario Fire Department on 02/29/2024 for four (4) ambulatory clients.The facility has three (3) client bedrooms, one (1) staff room and two (2) bathrooms. There is a kitchen, a lobby area, a dining area, a living room, a laundry room, and a backyard. LPAs Hernandez and Brown 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 107.2 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. Chemicals were locked underneath the kitchen sink. The facility has a posted meal schedule. There were seven (7) day non-perishable food inside the pantry and two (2) day perishable food inside the refrigerator/freezer.

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. ** Continuation on LIC809C **
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DE RAMOS HOME-ONTARIO
FACILITY NUMBER: 365530215
VISIT DATE: 09/25/2024
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***Continued from LIC 809***
Laundry Room/ Garage: 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, carbon monoxide, firearms: There is one charged fire extinguishers in the facility. LPAs observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and ammunition.

Postings: LPAs 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 and emergency kits. The facility has a working land line and telephone for clients’ use.

LPAs Hernandez and Brown observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPAS Brown and Hernandez audited three (3) client's medications and reviewed three (3) clients and two (2) staff file. No issues were observed. LPAs Hernandez and Brown have determined that the facility meets the operational requirements for licensure. The Pre-licensing 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. An exit interview was conducted, and this report, LIC809 and LIC809C was discussed and provided to Administrator Isabelita De Ramos.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
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