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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402684
Report Date: 11/03/2023
Date Signed: 11/03/2023 12:24:26 PM

Document Has Been Signed on 11/03/2023 12:24 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:UNLIMITED QUEST INC VFACILITY NUMBER:
366402684
ADMINISTRATOR:ROSEBOROUGH, BRIDGETFACILITY TYPE:
775
ADDRESS:118 FOOTHILL BLVD #A1/A2/A3/A4TELEPHONE:
(909) 873-8319
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 45CENSUS: 49DATE:
11/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ratna Tobing, Program SupervisorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Unlimited Quest Inc.V Adult Day Program unannounced to conduct an Annual Inspection. LPA was greeted by Ratna Tobing, Program Supervisor and granted LPA entry. Program Supervisor notified Program Director, Alyssa Sandoval of LPA's arrival and met with LPA at the front of the facility. LPA introduced self and stated the purpose of the visit. LPA was provided with a space to work and given a walk through of the facility.

A tour of the facility was conducted inside and out of physical plant, the following was observed:
Facility: The facility is approved to provide services for 60 non-ambulatory adults. A capacity increase request was granted 11/4/03. Program Director reported the current census is 49. LPA observed that the facility is operating in the capacity and conditions approved by Community Care Licensing.
Physical Plant: The facility was maintained at a comfortable temperature. The facility includes 4 bathrooms and 1 changing room. Each bathroom contained sufficient amounts of paper towels, hand soap, trash bins and operational appliances. Also, each bathroom was equipped with securable cabinets used to keep incontinent supplies and air freshener. The facility is equipped with operational smoke/fire alarms, water sprinklers and carbon monoxide detectors. LPA also observed six fully charged fire extinguishers. Each one was last inspected November 2023. Program Supervisor reports, that the facility conducts fire drills on a monthly basis; and disaster drills every 6 months. The facility maintains a waiver for outdoor activity space. LPA observed that the outdoor activity space continues to meet requirements. Exterior and Interior pathways were free of clutter and unobstructed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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: UNLIMITED QUEST INC V
FACILITY NUMBER: 366402684
VISIT DATE: 11/03/2023
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Food Service: The facility does not provide meals for individuals, but maintains a kitchen area to prepare snacks, store individual's food and cooking classes. Sharp objects are kept secure in staff offices inaccessible to individuals. LPA observed that chemicals and toxins are secure in a hallway closet; along with additional infection control supplies. The facility maintains adequate emergency supplies of food and water for the individuals in case of a disaster or emergency. LPA measured the water temperature in the kitchen; and observed that temperature ranged between 103 to 113 degrees.
Care & Supervision: Facility has sufficient care staff. Program Supervisor reports that the facility staffs' in a 3:1 ratio. One staff member for every 3 individuals.
Record Review and Resident/Staff Files: LPA reviewed three staff files. Each staff records/file were complete and current with training and background/fingerprint clearance; per regulation. LPA reviewed five individuals' files and found that each was complete with current Needs and Services Plans, Physician Reports, and Individual Programs Plans completed by the facility and/or Inland Regional Center.

Based on observations and record reviews, technical violations will be issued to address a concern for a restricted healthcare plan and a staff file. An exit interview was conducted where this report was reviewed, discussed and provided to Program Director, Alyssa Sandoval
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC809 (FAS) - (06/04)
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