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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366405847
Report Date: 01/23/2025
Date Signed: 01/23/2025 01:24:48 PM

Document Has Been Signed on 01/23/2025 01:24 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HOWARD HOMEFACILITY NUMBER:
366405847
ADMINISTRATOR/
DIRECTOR:		TOLENTINO, LILIAN MA.FACILITY TYPE:
735
ADDRESS:4361 HOWARD AVENUETELEPHONE:
(909) 627-2546
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY: 6CENSUS: 6DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Fermin Agrisola, House ManagerTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 1/23/2025 at 09:40 AM, Licensing Program Analyst (LPA) Eldin Serrano conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPA was greeted by House Manager (HM) Fermin Agrisola and gained access at the home. LPA explained the purpose of the visit to HM and he immediately called the licensee to come to the facility. The Licensee Judy Tolentino arrived an hour later.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). The facility is licensed for 6 non-ambulatory. LPA Serrano completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA observed three (3) client during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 70 degrees Fahrenheit. LPA Serrano inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting. LPA Serrano inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 135.5 degrees Fahrenheit which is above regulation. Citation will be issued. The licensee adjusted the water heater's thermostat and the citation is corrected during the visit. The facility is equipped with operational smoke detectors and carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book.

Posters such as the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HOWARD HOME
FACILITY NUMBER: 366405847
VISIT DATE: 01/23/2025
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Yards/Outside: One shaded patio, two (2) side gates with self-latching handle on the right side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA Serrano observed two (2) day(s) supply of perishable food and more than seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed four (4) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPA observed files reviewed were complete. LPA also reviewed four (4) staff file for First Aid/CPR certification, emergency intervention certification (CPI), criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result and observed files were complete.

LPA audited four (4) clients’ medications and no issues were observed. LPA audited four (4) clients’ Personal and Incidental (P&I) and no issues observed.

Deficiency was cited during this visit. An exit interview was conducted where this report LIC809, LIC809C LIC809D, and Appeal Rights were discussed, and copies were provided to House Manager Fermin Agrisola.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2025 01:24 PM - It Cannot Be Edited


Created By: Eldin Serrano On 01/23/2025 at 12:56 PM
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: HOWARD HOME
FACILITY NUMBER: 366405847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring that the water temperature coming out of the clients bathroom water faucet was within the regulation requirements. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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Licensee already adjusted the water heater's temperature and the citation is already corrected during the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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