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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402567
Report Date: 06/23/2023
Date Signed: 06/23/2023 02:47:07 PM

Document Has Been Signed on 06/23/2023 02:47 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:INLAND ADULT DEVELOPMENTAL CENTERFACILITY NUMBER:
366402567
ADMINISTRATOR:DORIS EKANEMFACILITY TYPE:
775
ADDRESS:10221-B TRADEMARK STREETTELEPHONE:
(909) 483-1310
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY: 45CENSUS: 36DATE:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ninik IlyasTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Assistant Director Ninik Ilyas and was granted entry to the facility. At the time of the visit there was eleven (11) staff,and twenty-eight (28) clients present. The facility is an Adult Day Program (ADP) facility Licensed capacity is (45) current census (36). LPA was accompanied by Ninik 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. Assistant Director confirmed that carbon monoxide detectors and fire alarms and sprinklers are maintained and monitored annually by outside vendor through the regional office and fire extinguishers are maintained and monitored by Fire Department. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients. There was a designated storage space for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions.

Food Service: At Day Program, clients are responsible to bring their own lunch. Facility has emergency snacks, and emergency water available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Day Program has sufficient care staff for coverage 6 hours mon-fri. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed five (5) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: INLAND ADULT DEVELOPMENTAL CENTER
FACILITY NUMBER: 366402567
VISIT DATE: 06/23/2023
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Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Assistant Director Ninik Ilyas.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
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