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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366405847
Report Date: 03/06/2023
Date Signed: 03/06/2023 11:25:17 AM

Document Has Been Signed on 03/06/2023 11:25 AM - 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:HOWARD HOMEFACILITY NUMBER:
366405847
ADMINISTRATOR:TOLENTINO, LILIAN MA.FACILITY TYPE:
735
ADDRESS:4361 HOWARD AVENUETELEPHONE:
(909) 627-2546
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY: 6CENSUS: 5DATE:
03/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Patrice Amon, Facility ManagerTIME COMPLETED:
11:15 AM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Howard Home Adult Residential Facility to conduct an annual inspection. LPA was greeted and granted entry by Patrice Amon, Facility Manager, (FM)
LPA had temperature taken and was provided a space to work, while FM contacted the Facility Administrator who arrived later during the visit. There are currently 5 residents in care with no concerns or suspected COVID Cases. LPA met 3 additional staff members during the visit.

FM provided LPA with a walk through the facility inside and outside. LPA observed the following:

Kitchen - cleanly, free of debris or obstruction. Sharp objects are kept in a secure drawer next to the stove. Chemicals kept secure under the sink. The facility centrally stores resident medications in a secure cabinet in the kitchen. Pantries next to refrigerator contained appropriate amounts of food for residents in care. Food located in good standing.

Backyard - LPA observed adequate seating and shade made available to residents. Pathways along the sides of facility are free of obstructions. No bodies of water observed on grounds.

Resident Rooms - each room included a bed, night stand, storage and adequate lighting. All of which observed in good repair. Extra linens are kept in a hallway closet.

Bathrooms - orderly with adequate amount of hand soap and paper supplies. Toilets and faucets free of mold/mildew and functional. Hygiene products kept under the sink.

Fire extinguishers last inspected August 2022. Smoke/Carbon Monoxide alarms tested and found in working order.

LPA observed no deficiencies during the visit. An exit interview was conducted a where this report was discussed then provided to Facility Representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2023
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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