366405852-1-17-2025-56-AS-LFAW-DD247D-20250117175058

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366405852
Report Date: 01/17/2025
Date Signed: 01/17/2025 05:52:28 PM

Document Has Been Signed on 01/17/2025 05:52 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:	TEENEE'S HOUSE		FACILITY NUMBER:	366405852
ADMINISTRATOR/ DIRECTOR:	RODANTE CANLAS		FACILITY TYPE:	740
ADDRESS:	801 WISTERIA AVENUE		TELEPHONE:	(909) 874-8019
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY: 5	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	01/17/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:28 AM
MET WITH:	Thelma Agpalo, Lead Staff		TIME VISIT/ INSPECTION COMPLETED:	02:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) LaVette Farlow arrived unannounced to conduct the required annual visit to the facility. LPA met with Lead Staff Thelma Agpalo, and introduced self and stated purpose of the visit. LPA asked Lead staff to notify the administrator of my arrival. LPA was informed that there are currently 3 residents in care who are in the facility. The facility has (3) resident bedrooms, (2) resident bathrooms, (2) staff sleeping quarters, living room, dining area, kitchen, backyard, and attached garage. LPA completed a walk through of facility and review of records. 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 of 71 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. LPA tested the water temperature and the reading were extremely hot. Staff attempted to correct the temperature and were unsuccessful. The water temperature tested 123.5, 125.9, and 135.1 degrees Fahrenheit. Deficiency issued. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. There was a designated storage space for resident/staff files. Resident medications were observed secured and inaccessible to residents. There are no guns, ammunition, swimming pool or bodies of water in the facility. 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. Dishes, cups, and utensils were also stored properly.

Nedra Brown	TELEPHONE: (951) 202-5776
Lavette Farlow	TELEPHONE: 951-248-0304
	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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: TEENEE'S HOUSE	FACILITY NUMBER: 366405852
	VISIT DATE: 01/17/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard, a garage housing the washer and dryer. All outdoor pathways were free of obstructions.

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

Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed issues with 1 of 3 resident records indicting the resident is bedridden. The facility does not have a fire clearance to admit or maintain a resident who is bedridden or to, maintain or remain in, residential care facilities for the elderly. Deficiency issued. Also, after reviewing the resident LIC 602 it was observe that the Physician Report does not have current medical condition and after interviewing staff and Physician it was reported that the resident is bedridden. Deficiency issued. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPA observed that the facility completes monthly disaster drills and was able to provide proof of the last drills conducted in December 2024. LPA observed that the Emergency Disaster Plan was reviewed/updated May 2024.

Three Deficiencies, were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, and LIC809D, and appeal rights were discussed and copies were provided to Thelma Agpalo.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Lavette Farlow	TELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 01/17/2025 05:52 PM - It Cannot Be Edited

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: TEENEE'S HOUSE	FACILITY NUMBER: 366405852
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 1 rooms in the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2025
	Plan of Correction
1 2 3 4	Licensee agreed to submit a request for a fire clearance and make the needed correction or relocation if needed.

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.

Nedra Brown	TELEPHONE: (951) 202-5776
Lavette Farlow	TELEPHONE: 951-248-0304
	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/17/2025 05:52 PM - It Cannot Be Edited

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: TEENEE'S HOUSE	FACILITY NUMBER: 366405852
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 3 water faucets which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Licensee agreed to have a plumber come out to adjust the temperature and check the water heater.

Section Cited

Reappraisals

(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 3 residents in care physicians report LIC 602 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2025
	Plan of Correction
1 2 3 4	Licensee agreed to request an updated Physician Report from the doctor and will maintain any changing in conditions.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Nedra Brown	TELEPHONE: (951) 202-5776
Lavette Farlow	TELEPHONE: 951-248-0304
	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4