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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408346
Report Date: 02/22/2022
Date Signed: 02/22/2022 01:44:03 PM

Document Has Been Signed on 02/22/2022 01:44 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:SALEM SOUTH HOMEFACILITY NUMBER:
366408346
ADMINISTRATOR:ANNA LOPEZFACILITY TYPE:
735
ADDRESS:2326 S. CUCAMONGATELEPHONE:
(909) 218-4411
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 12CENSUS: 11DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administer -Anna LopezTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA), Bernadette Allen and Rohit Lama, conducted an unannounced required annual visit to the facility and was granted entrance by the Administrator Anna Lopez.. LPA Allen and Lama conducted an inspection of the facility both interior and exterior. Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected and no deficiencies were noted.

Interior/Exterior: The home consists of 8 client bedrooms, seven bathrooms, a living room, a kitchen/dining room, and a garage. The facility also has a two bedroom, one bath apartment (attached) with a kitchenette, which was previously used for the live in manager. This apartment is off the main living room, it is being used for two of the clients. The residents bedrooms were inspected and the following was observed; single bed, night stand, and there is sufficient dresser/closet space for residents belongings. The facility has an adequate supply of bed linens and bath towels for residents.

Bathrooms have grab bars and and slip resistant mats in the shower. The water temperature was measured at 105.2 degrees F. The facility has the minimum requirement of two days perishable and seven days non-perishable supply of food items. Smoke/carbon monoxide detectors are operable and checked on a monthly basis. The last fire drill was conducted on 2/6/2022 and disaster drill will be conducted on 2/28/2022. Their prior drill was on 1/6/2022.

The chemicals are locked and stored in a cabinet in the laundry room. The knives are locked in a kitchen drawer by the stove. Medications are stored and locked and are located in the medication room.

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 Anna Lopez.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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