366407059-9-11-2023-56-AS-ABUO-CVKPY4-20230911114318

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366407059
Report Date: 09/11/2023
Date Signed: 09/11/2023 11:43:32 AM

Document Has Been Signed on 09/11/2023 11:43 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	RAINBOW GUEST HOME		FACILITY NUMBER:	366407059
ADMINISTRATOR:	MENCIAS, MARIO		FACILITY TYPE:	740
ADDRESS:	11205 DAYLILLY ST.		TELEPHONE:	(909) 357-0144
CITY:	FONTANA	STATE: CA	ZIP CODE:	92337
CAPACITY:	6	CENSUS: 4	DATE:	09/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Mario Mencias		TIME COMPLETED:	11:46 AM

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) Anna Bueno conducted an unannounced visit to the facility to conduct a required annual inspection. LPA identified herself to licensee Mario Mencias who was advised of the purpose of the visit. The facility is currently licensed as a Residential Care Facility for Elderly, vendored by the Inland Regional Center. The facility has capacity of six ambulatory clients and presently have four clients. Two of four clients were present during today's visit. LPA Bueno and Licensee Mencias toured the interior and exterior of the facility. Buildings and Grounds: The home has four bedrooms -one of which is the staff room, two (2) bathrooms -one of which are dedicated for resident use, a den/office area, a laundry area, a living and sitting area, and a kitchen and dining area. The facility has no bodies of water. There is a backyard with shaded area for resident use. LPA observed that the side gate is unlocked and free of obstruction. This facility has no bodies of water. LPA observed that side gate is unlocked and free of obstruction. The facility has a working telephone available for use. The facility fire extinguisher was last inspected on 06/14/2023. Licensee tested resident bedroom smoke alarms and hallway carbon monoxide detectors and LPA and Licensee found all units to be in working order Storage and Supplies: Activities were observed to be available in the office area and in resident rooms and appear to be a sufficient amount. A locked centralized cabinet is utilized for medications while client and staff files are secured in the office. Sharps are kept locked while toxins and cleaning agents are secured in cabinets, inaccessible to residents. The first aid kit was observed to be available and complete. Linens, and equipment are all in good repair and sufficient for approved census. LPA and Licensee observed at least two days of perishable food items and 7 days of non-perishables. Food Service and Laundry: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. There is a secured storage for sharps, and cleaning supplies and toxins were locked in a closet.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: RAINBOW GUEST HOME	FACILITY NUMBER: 366407059
	VISIT DATE: 09/11/2023

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Bedrooms and Bathrooms: Resident bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by Licensee and LPA and Licensee observed the temperature to be 110 degrees Fahrenheit.

Facility Files and Medication: LPA inspected four of four resident files and found that it had the required documentation including an admissions agreement, physician's report, and Individual Program Plan (IPP). LPA reviewed three of three staff files and found current first aid certifications and training verifications. LPA reviewed four sets of resident medications and found that the medication is being administered as prescribed. LPA also reviewed updated LIC 500, personnel report, and LIC 610E, emergency disaster plan.

No deficiencies were issued during today's visit. An exit interview was conducted where this report was discussed and a copy was provided to Licensee Mencias at the conclusion of the inspection.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

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