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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366403557
Report Date: 09/25/2024
Date Signed: 09/25/2024 03:08:56 PM

Document Has Been Signed on 09/25/2024 03:08 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 IIIFACILITY NUMBER:
366403557
ADMINISTRATOR/
DIRECTOR:		PAIRO, RAUL R.FACILITY TYPE:
735
ADDRESS:18815 WRANGLER DRIVETELEPHONE:
(909) 879-0226
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY: 6CENSUS: 4DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:46 PM
MET WITH:Joseph Pairo- ManagerTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA’s) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Joseph Pairo Manager who assisted with the tour of the facility. The four (4) clients were at day program at the time of the visit.

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 resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The water was measured at 103.2 degrees.

LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors, fully charged fire extinguisher, 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 residents in care.

LPA observed there was a designated storage space for resident/staff files and medications are kept locked in a closet next to kitchen inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care.

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 two (2) resident files for admission agreements, updated physician reports, and needs and services plans.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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 III
FACILITY NUMBER: 366403557
VISIT DATE: 09/25/2024
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LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. 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.

An exit interview was conducted, and this report was discussed and provided to Joseph Pairo at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
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