<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366401304
Report Date: 02/18/2022
Date Signed: 02/18/2022 09:43:29 AM


Document Has Been Signed on 02/18/2022 09:43 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:MARIA VICTORIA'S HOME CARE -AFACILITY NUMBER:
366401304
ADMINISTRATOR:CACHAPERO, HENRYFACILITY TYPE:
740
ADDRESS:11523 PEMBROKE STREETTELEPHONE:
(909) 799-1537
CITY:LOMA LINDASTATE: CAZIP CODE:
92350
CAPACITY:6CENSUS: 4DATE:
02/18/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Henry CachaperoTIME COMPLETED:
10:00 AM
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
Licensing Program Analyst (LPA) Stephanie Williams and Regional Manager (RM) Leslie Mendiveles made an unannounced visit to the facility in order to conduct a health and safety check of the residents in care. LPA Williams and RM Mendiveles identified themselves to Administrator, Henry Cachapero , who was also informed of the purpose of this visit. LPA Williams and RM Mendiveles inspected the facility for regulatory compliance and made observations in regard to the well-being of residents in care.

At the time of visit, there were approximately four residents in care, of which none were on hospice or bedridden. LPA Williams and RM Mendiveles observed residents laying down in their beds and sitting at the dining table. It appeared that there was no imminent danger to the residents health or well-being upon inspection of the facility. Furthermore, there was one staff member present at the facility to care for the residents. Upon interviewing the Administrator, Cachapero stated that the facility has adequate staff to care for residents and a plan in place to address any staff shortcomings.

In addition, LPA Williams and RM Mendiveles toured all areas of the facility, including resident bedrooms, bathrooms, and common areas. It was observed that utilities such as the electricity, gas, and water were functioning at the time of visit. LPA Williams inspected the facility's food supply and observed an adequate supply of perishable and non-perishable food. LPA Williams observed that dangerous items, medications, and cleaning supplies were inaccessible to residents. LPA Williams determined that there were no concerns of the residents' care and supervision at the time of visit.

No deficiencies cited at this time. An exit interview was conducted where this report (LIC 9099) was discussed and a copy of this report was provided to the Administrator at the conclusion of the visit.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1