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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402892
Report Date: 04/15/2024
Date Signed: 04/15/2024 03:17:53 PM

Document Has Been Signed on 04/15/2024 03:17 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/
DIRECTOR:		PAIRO, RAULFACILITY TYPE:
735
ADDRESS:1233 MICHAEL DARCY ST.TELEPHONE:
(909) 825-2710
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY: 4CENSUS: 4DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Naomi Pairo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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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 Facility Administrator Naomi Pairo and was granted entry to the facility. At the time of the visit there was two (2) staff present, and one (1) client present. Three clients was attending Day Program. The facility is a four (4) bedroom, two (2), bathroom home, with a kitchen/dining area, and living room. The facility is an Adult Residential Facility (ARF) level 3 designated home vendorized by Inland Regional Center. Licensed capacity is (4) current census (4). LPA was accompanied by Facility Administrator Naomi Pairo 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 bathrooms to be at 108.1 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. 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 in care. There was a designated storage space for client/staff files. Medications are kept inside medication closet inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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: PAIRO'S ADULT RESIDENTIAL II
FACILITY NUMBER: 366402892
VISIT DATE: 04/15/2024
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Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

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.

Record Review: LPA reviewed four (4) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I fund were counted and matched with the ledger. Medications were audited at random and appeared to be dispensed appropriately by staff members.

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 Facility Administrator Naomi Pairo.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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