366401304-9-17-2023-56-AS-BALN-CVRRAX-20230917125153

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366401304
Report Date: 09/17/2023
Date Signed: 09/17/2023 12:52:05 PM

Document Has Been Signed on 09/17/2023 12:52 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 -A		FACILITY NUMBER:	366401304
ADMINISTRATOR:	CACHAPERO, HENRY		FACILITY TYPE:	740
ADDRESS:	11523 PEMBROKE STREET		TELEPHONE:	(909) 799-1537
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92350
CAPACITY:	6	CENSUS: 3	DATE:	09/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Melita Cachapero-Licensee		TIME COMPLETED:	01:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to the facility for the purpose of conducting an annual inspection. LPA identified herself and was granted entry. LPA met with Administrator, Henry Cachapero, and Licensee Melita Cachapero was also present at the time of visit. The facility is licensed for a capacity of (6) non-ambulatory residents, at the time of visit 3 residents were in care.

LPA observed a swimming pool in backyard, gate was safely secured by locked iron a gate around the perimeter. LPA was informed that no firearms, weapons, or ammunition is kept at the facility.

LPA walked through the interior and exterior of grounds with the administrator. LPA observed all passageways were clear of obstructions and facility to be maintain at a comfortable temperature. Exit gates were identified to be unlocked. LPA observed a cover patio with appropriate seating for residents in care in front and backyard.

LPA observed facility to have appropriate (2) day supply of perishable and (7) day supply of non-perishable food storage for residents. The food appeared to be selected, prepared, and stored in a healthful manner. The knifes and sharps are kept in garage locked.

The kitchen was observed to be in clean condition and had ample supply of dishware and cook ware. cleaning supplies, detergent, and disinfectants were inaccessible to residents and kept in laundry room locked.

LPA observe facility to have emergency disaster supplies and complete First Aid kit. Last fire drill was last conducted on 8/1/2022 and one will be conducted on 9/18/2023 per Henry. The Carbon monoxide detectors were observed to be operable and fire extinguishers fully charged.

Hot water temperature was measured throughout the residence and measured at between 105-120 degrees Fahrenheit. The bathrooms were clean and free of odor with operable toilets. LPA observed non-skid mats or strips in showers and tubs.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MARIA VICTORIA'S HOME CARE -A	FACILITY NUMBER: 366401304
	VISIT DATE: 09/17/2023

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The resident’s bedrooms are clean and appropriately furnished. LPA observed an adequate supply of extra linens and towels. LPA observed a sufficient supply of hygiene items stored for residents.

Medication was observed to be in a centrally stored location in hallway within a filing cabinet locked. Medication was observed to have appropriate labels and in compliance with state and federal laws.

An exit interview was conducted with Administrator, where this report was discussed and provided at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2023

LIC809 (FAS) - (06/04)

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