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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530244
Report Date: 11/21/2024
Date Signed: 11/21/2024 09:40:21 AM

Document Has Been Signed on 11/21/2024 09:40 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:AEN CALETA HOMEFACILITY NUMBER:
365530244
ADMINISTRATOR/
DIRECTOR:		CHEA NGUYEN, SOKSANROZAFACILITY TYPE:
735
ADDRESS:11956 CALETA WAYTELEPHONE:
(562) 896-2299
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 3CENSUS: 0DATE:
11/21/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Soksanroza, NguyenTIME VISIT/
INSPECTION COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced visit to conduct the Pre-licensing inspection. LPA met with Licensee, Soksanroza Nguyen. The fire clearance was approved on 8/08/2024 for three (3) ambulatory clients.

The facility has three (3) client bedrooms, two (2) client bathrooms, one (1) staff bedroom with bathroom, living room, kitchen, pantry, dining area, activity room, laundry room, attached garage and back yard. LPA 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.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter top were free of debris and in good repair. The water temperature was measured at 113.6 degrees fahrenheit. There was a locked and secured location where medication, sharps, chemicals and clients/staff files will be stored. There was non-perishable food in the pantry and perishable food in the refrigerator.

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

Laundry Room/ Garage: The laundry room is next to the kitchen. Chemicals, laundry soap and toiletries were safely locked.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AEN CALETA HOME
FACILITY NUMBER: 365530244
VISIT DATE: 11/21/2024
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Backyard: There is one (1) shed used for storage, one (1) greenhouse, a side gate with self-latching handle on the right side of the house that leads into the backyard and no bodies of water. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There is one charged fire extinguisher in the facility. LPA observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and ammunition.

Postings: LPA observed required postings including the emergency/disaster plans, house rules, visiting policy, and personal rights.

First aid and telephone: The facility was equipped with a complete first aid kit and emergency kits. The facility has a functioning land line and telephone for clients use.

Pre-Licensing and Comp III are complete and ready for licensure.


An exit interview was conducted, and this report was discussed and provided to Licensee, Soksanroza Nguyen.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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