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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400113
Report Date: 10/09/2024
Date Signed: 10/09/2024 02:41:23 PM

Document Has Been Signed on 10/09/2024 02:41 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GARDENFACILITY NUMBER:
366400113
ADMINISTRATOR/
DIRECTOR:		MICHAEL BRLETICHFACILITY TYPE:
735
ADDRESS:9212 GARDEN STREETTELEPHONE:
(909) 941-4449
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 4DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:LaTasha Love-Moore, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst (LPAs) La Vette Farlow and Bernadette Allen arrived unannounced to conduct the required annual visit to the facility. LPAs met with Manager, LaTasha Love-Moore, and introduced themselves and stated purpose of the visit. LPAs were informed that 1 clients was at the day program and 3 present in the home.

The facility has 4 resident bedrooms, 2 bathrooms, office with a bed, kitchen, dining area, family room, living room, laundry room with a toilet, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPAs completed a walk through of facility, review of records, medication and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees fahrenheit. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPAs inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 109.5 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher with an inspection date of June 2024. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in the office. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were observed in secure cabinets and inaccessible to clients. The facility had emergency kits in the garage for clients in care. There are no firearms, ammunition, pool or bodies of water in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.
Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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: GARDEN
FACILITY NUMBER: 366400113
VISIT DATE: 10/09/2024
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Yards/Outside: LPAs observed one shaded patio, a side gates with self-latching handle on the left side and right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPAs reviewed 2 client files for admission agreements, updated physician reports, and needs and services plans. LPAs also reviewed Licensee and staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I funds and medications were audited and appeared to be managed appropriately. The facility last conducted a disaster drill on October 4, 2024.

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, and LIC809C were discussed and copies were provided to the, Manager LaTasha Love-Moore.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
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