366405852-12-15-2023-56-AS-BWOT-CYJVY4-20231215155030

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366405852
Report Date: 12/15/2023
Date Signed: 12/15/2023 03:51:41 PM

Document Has Been Signed on 12/15/2023 03:51 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:	RODANTE CANLAS		FACILITY TYPE:	740
ADDRESS:	801 WISTERIA AVENUE		TELEPHONE:	(909) 874-8019
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	5	CENSUS: 5	DATE:	12/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Marcy Alcanpara, staff member		TIME COMPLETED:	03:55 PM

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Licensing Program Analysts, Amber Coleman, (LPA Coleman) and Bianca Wolcott, (LPA Wolcott) arrived at the Teenee House, Residential Care Facility for the Elderly to conduct an Annual Inspection. LPAs were greeted by staff members, Marcy Alcanpara and Phelma Agalo and granted entry. LPAs introduced themselves and stated purpose of the visit. LPA’s signed in and were provided a space to work.

While signing in, LPA observed a COVID station which included PPE, hand sanitizers and information regarding infection control. All made accessible to those who visit the facility and its residents. Accompanied by Marcy Alcanpara, LPA’s was completed a walk through of the facility.

Personnel Records/Training/and Staffing- LPA reviewed three, (3) employee records, for first aid certification, fingerprint/criminal background clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights and training verification, and current administrator certification.

Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental- LPA reviewed four resident files for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA found that each of the resident files included all above mentioned documents included in the residents files.

Resident Rooms - Each resident bedroom can accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with beds, chairs, closets for storage space, appropriate linens, adequate lighting, and an functional smoke and carbon monoxide alarms.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca Wolcott	TELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TEENEE'S HOUSE	FACILITY NUMBER: 366405852
	VISIT DATE: 12/15/2023

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Bathrooms: All bathrooms included operational appliances, an adequate supply of towels, toilet paper, and toiletries. Handrails were observed in each bathroom.

Food Service- Food preparations areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables food on hand. Food Menus posted.

General: Disaster drills are completed on a monthly basis. Fire Extinguisher last inspected November 2023.

No deficiencies observed during today's visit. An exit interview was conducted where this report was discussed and provided to the Facility Representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca Wolcott	TELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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