<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408115
Report Date: 05/24/2022
Date Signed: 05/24/2022 04:11:32 PM

Document Has Been Signed on 05/24/2022 04:11 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
, CA 92507
FACILITY NAME:MIRACLE HOMEFACILITY NUMBER:
366408115
ADMINISTRATOR:SAMSON, MILAGROSFACILITY TYPE:
735
ADDRESS:10990 BLACKWOOD COURTTELEPHONE:
(909) 600-7159
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 6CENSUS: 4DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Milagros SamsonTIME COMPLETED:
04:13 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
At 3:10 PM, Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility in order to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. At 3:14 PM, Lordeth Bonilla, care staff, granted entry to LPA and staff who verified there are no active and/or suspected Covid-19 cases in the home. Licensees Rempson and Milagros Samson were phoned by staff and arrived shortly.

During today's visit, LPA Bueno and staff toured the facility inside and LPA and Mrs. Samson toured the outside. LPA interviewed Licensees regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed appropriate postings in the facility, including COVID-19 symptoms postings and personal rights postings, which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and emergency personnel in the event the client presents with COVID-19 symptoms.

LPA Bueno observed that the facility appears to be meeting operational requirements. LPA observed that all utilities and appliances were functioning properly and all passageways clear of obstruction, including emergency exits. The facility was equipped with sufficient food supplies. ****************CONTINUED ON LIC809-C****************
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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 2
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: MIRACLE HOME
FACILITY NUMBER: 366408115
VISIT DATE: 05/24/2022
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
All areas of the facility, including client's bedroom and bathroom, appeared to have appropriate furnishings, are clean, and in good repair. LPA observed that medications and dangerous objects were kept inaccessible to clients in care. LPA Bueno observed no apparent health and safety risks at the time of visit.

Based on interviews and observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed and a copy of this report was provided to Mrs. Samson at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2