366403557-9-11-2023-56-AS-MMAE-CVKQCZ-20230911120359

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366403557
Report Date: 09/11/2023
Date Signed: 09/11/2023 12:05:09 PM

Document Has Been Signed on 09/11/2023 12:05 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:	PAIRO'S ADULT RESIDENTIAL III		FACILITY NUMBER:	366403557
ADMINISTRATOR:	PAIRO, RAUL R.		FACILITY TYPE:	735
ADDRESS:	18815 WRANGLER DRIVE		TELEPHONE:	(909) 879-0226
CITY:	BLOOMINGTON	STATE: CA	ZIP CODE:	92316
CAPACITY: 6		CENSUS: 4	DATE:	09/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Naomi Pairo, Administrator		TIME COMPLETED:	12:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required 1-year visit to the facility. LPA met with Naomi Pairo, Administrator and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), license capacity of (6) with a current census of (4). Facility is vendorzied through Inland Regional Center (IRC).LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPA inspected the facility inside and out. Indoor and outdoor passageways are kept free of obstruction. Facility has no bodies of water. Facility backyard is fenced with self-latching gate. Facility living room, dining room, family room furniture are in good repair and sufficient for clients in care. The facility has sufficient lighting and is maintained at a comfortable temperature.

LPA observed posted client activities include movie nights, arts and crafts, community outings and day program participation.

LPA inspected the kitchen. Hot water temperature tested at 105 degrees F. Facility has sufficient non-perishable and perishable food for number of clients in care. Facility food is stored in a safe and healthful manner. Facility has sufficient cups, plates, and utensils for client use. Sharps, disinfectants, and chemicals are kept locked and inaccessible to clients in care.

LPA inspected client bedrooms. Bedrooms are equipped beds, bed linen, nightstands, chairs, and sufficient lighting.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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: PAIRO'S ADULT RESIDENTIAL III	FACILITY NUMBER: 366403557
	VISIT DATE: 09/11/2023

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LPA inspected client bathroom. Bathroom is equipped with grab rails and operating in a safe manner. Hot water temperature tested at 106 degrees F.

The facility is equipped with carbon monoxide alarm. Emergency drill was conducted on 5/31/23. Facility has posted in a common area the personal rights, disaster plan and emergency numbers. Facility has complete first aid kits and emergency supplies. Facility has sufficient supply of linen and hygiene products for clients in care. LPA called the facility landline and the call went to a voice system that was not set-up. Administrator stated that the facility landline is currently being used as a fax and is not sure how to switch to telephone service. Deficiency cited.

LPA inspected client medications. Medications are labeled and administered as prescribed. Medications are kept locked and inaccessible to clients in care.

LPA reviewed client files for admission agreements, Individual Program Plan (IPPs), physician reports, medical assessments, and record of client safeguarded resources, all had the required documentation.

LPA reviewed staff files for criminal record clearances, training, and health screenings, all had the required documentation.

An exit interview was conducted, where licensing reports and a plan of correction was discussed. Copies of the reports with appeal rights were provided to the Administrator, at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/11/2023 12:05 PM - It Cannot Be Edited

Created By: Magda Malcore On 09/11/2023 at 11:49 AM

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
RIVERSIDE, CA 92507

FACILITY NAME: PAIRO'S ADULT RESIDENTIAL III	FACILITY NUMBER: 366403557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80073(a)

Telephones

(a) All facilities shall have telephone service on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above by LPA called the facility landline and the call went to a voice system that was not set-up, Administrator stated that the facility landline is currently being used as a fax and is not sure how to switch to telephone service, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator shall provide to the licensing agency proof of operating telephone services on the premise 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:

Magda Malcore

LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

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