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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366401304
Report Date: 12/16/2022
Date Signed: 12/16/2022 12:32:16 PM


Document Has Been Signed on 12/16/2022 12:32 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: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: 3DATE:
12/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Henry & Melita Cachapero-LicenseeTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to conduct a Health and Safety check of the clients in care at the facility. LPA Allen met with Henry & Melita Cachapero and explained the reason for the visit.

LPA Arrived at the facility and observed 3 residents in care. Melita and Henry said that no residents are on hospice or bedridden. LPA Allen observed two (2) residents in the dining area and one (1) resident in the TV room.

It appeared that there was no imminent danger to the resident’s health or well-being upon inspection a of the facility. There was two staff member present to care for the residents. Upon interviewing Henry & Melita they stated that the facility has adequate staff to care for residents and a plan in place to address any staff shortcomings. In addition, LPA Allen 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 Allen inspected the facility's food supply and observed an adequate supply of perishable and non-perishable food.

LPA Allen observed that dangerous items, medications, and cleaning supplies were inaccessible to residents. LPA Allen 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 809) was discussed and a copy of this report was provided at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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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