366401710-11-29-2023-56-AS-JPRO-CY2TQW-20231129135637

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366401710
Report Date: 11/29/2023
Date Signed: 11/29/2023 01:56:48 PM

Document Has Been Signed on 11/29/2023 01:56 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:	MLM HOME		FACILITY NUMBER:	366401710
ADMINISTRATOR:	LULU MEDINA		FACILITY TYPE:	735
ADDRESS:	6831 ARTHUR COURT		TELEPHONE:	(909) 248-1048
CITY:	CHINO	STATE: CA	ZIP CODE:	91710
CAPACITY: 6		CENSUS: 4	DATE:	11/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Lulu Medina, Administrator		TIME COMPLETED:	02:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Licensee Lulu Medina and was granted entry to the facility. At the time of the visit there was one (1) staff present, and one (1) resident were present. The facility is a five (5) bedroom, three (3), bathroom home, with a kitchen/dining area, living room, and detached garage. The facility is an Adult Residential (ARF) level 2 designated home, vendored by Inland Regional Center. Licensed capacity is (6) current census (4). LPA was accompanied by licensee Lulu Medina , to conduct a general overall inspection, which included, but was not limited to, the following:

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. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the kitchen to be at 110.0 degrees F. The facility is equipped with smoke detectors, one of which was observed to be not operational and carbon monoxide alarm, which was found to be not operational. Posters such as personal rights were observed. The disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care.

***Continued on LIC 809 C

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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: MLM HOME	FACILITY NUMBER: 366401710
	VISIT DATE: 11/29/2023

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There was a designated storage space for client/staff files. Medications are kept inside lock box inaccessible to clients. 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.

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

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

LPA Prieto informed Licensee Medina that deficiency will be issued as this poses potential health, and safety risk to residents in care.

An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were discussed and provided to Licensee Medina.

An exit interview was conducted, and this report was discussed and provided to Lulu Medina.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/29/2023 01:56 PM - It Cannot Be Edited

Created By: Javier Prieto On 11/29/2023 at 01:19 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MLM HOME	FACILITY NUMBER: 366401710
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1503.2

General Provisions

Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of one total count which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/30/2023
	Plan of Correction
1 2 3 4	Licensee to replace carbon monoxide detector or battery of dector by POC date

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Karen Clemons

LICENSING EVALUATOR NAME:

Javier Prieto

LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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