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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366406409
Report Date: 02/09/2022
Date Signed: 02/09/2022 02:22:01 PM

Document Has Been Signed on 02/09/2022 02:22 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
RIVERSIDE, CA 92507
FACILITY NAME:BLUE JAY HOMEFACILITY NUMBER:
366406409
ADMINISTRATOR:RAMONA RUELASFACILITY TYPE:
735
ADDRESS:414 E. BLUE JAY WAYTELEPHONE:
(909) 218-4396
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 4CENSUS: 4DATE:
02/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Manager Rebecca PantojaTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Bernadette Allen arrived unannounced to conduct an Annual Required Inspection to ensure facility is following Title 22 Regulations. LPA met with Manager, Rebecca Pantoja. The facility is licensed for four (4) Non- Ambulatory clients with Developmental Disabilities. There were two (2) staff members, and four (4) clients present during the inspection.

LPA Bernadette Allen toured the inside and outside of the facility. There are no bodies of water or firearms on the premises. The hallways are free of obstruction. The disinfectants, cleaning solutions and poison are locked in the kitchen and laundry area of the garage. There is enough lighting to ensure safety to clients in care. The hot water was measured at 104.3 degrees Fahrenheit. The toilets, sinks, and showers were sanitary and in operating condition with accessibility for handicapped clients. Clients had the proper bedding and there was enough towels and washcloths on hand. The smoke alarms in the client’s bedrooms and the Carbon Monoxide Detector were operational. Fire extinguishers last inspected 2/8/2022.

The food was stored in a healthful manner. There was a minimum of one week of non- perishable foods and two days for perishable foods. LPA observed food was protected against contamination. There was enough staff to ensure provisions of care and supervision to meet clients’ needs.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
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
RIVERSIDE, CA 92507
FACILITY NAME: BLUE JAY HOME
FACILITY NUMBER: 366406409
VISIT DATE: 02/09/2022
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Clients are provided healthful and comfortable accommodations. Medications were observed to be locked in the hall cabinets leading to garage and labeled appropriately.

LPA reviewed staff and resident files. Staff files had the required documentation including a health screening report, current first aid/CPR certification, and annual training. Resident files had the required documentation including an admission's agreement, updated physician's reports, and Individual Program.

Plans (IPP's). LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. LPA reviewed Personal and Incidental (P&I) funds. The P&I funds matched the ledger. No prohibited health conditions were observed. All staff records were current, and all training was up to date.

Based on this inspection, no deficiencies were observed at this time in the areas evaluated. An exit interview was conducted with the manager Rebecca Pantoja. A copy this report was given at the time of visit.

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

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC809 (FAS) - (06/04)
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