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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402892
Report Date: 03/18/2022
Date Signed: 03/18/2022 05:26:26 PM

Document Has Been Signed on 03/18/2022 05:26 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:PAIRO'S ADULT RESIDENTIAL IIFACILITY NUMBER:
366402892
ADMINISTRATOR:PAIRO, RAULFACILITY TYPE:
735
ADDRESS:1233 MICHAEL DARCY ST.TELEPHONE:
(909) 825-2710
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY: 4CENSUS: 2DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Fernando Oyama, House ManagerTIME COMPLETED:
09:42 AM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on infection control. LPA informed House Manager of the nature of the visit and was granted entry to the facility.

LPA toured the facility inside and out. The facility has no bodies of water. The facility has charged fire extinguishers, smoke alarms, and carbon monoxide detectors. Cleaning supplies and sharps were kept in a safe and locked room. LPA observed at least two (2) days supply of perishable food items and seven (7) days supply of nonperishable food items. The client bedrooms had the required furniture and sufficient lighting. Facility had a supply of additional linen and hygiene items.

LPA observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, clients, and visitors. LPA observed hand sanitizer throughout the facility and adequate supply of PPE and paper supplies. All residents have at least a 30 day supply of medications.

LPA observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed and a copy of this report was also provided to Mr. Oyama at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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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