366408346-1-13-2025-56-AS-PGUO-DCW4GK-20250113180541

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366408346
Report Date: 01/13/2025
Date Signed: 01/13/2025 06:05:48 PM

Document Has Been Signed on 01/13/2025 06:05 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SALEM SOUTH HOME		FACILITY NUMBER:	366408346
ADMINISTRATOR/ DIRECTOR:	ANNA LOPEZ		FACILITY TYPE:	735
ADDRESS:	2326 S. CUCAMONGA		TELEPHONE:	(909) 218-4411
CITY:	ONTARIO	STATE: CA	ZIP CODE:	91761
CAPACITY: 12		CENSUS: 10	DATE:	01/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	04:20 PM
MET WITH:	Anna Lopez- Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:15 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

Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Administrator Anna Lopez and was granted entry to the facility. The facility is a (10) bedroom (8) bathroom home and, with a kitchen/dining area, living room, attach garage. The facility is an Adult Residential Facility (ARF) level 3 designated home vendorized by Inland Regional Center. Licensed capacity is (12) current census (10). LPA was accompanied by Facility Administrator to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 115 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated space for client/staff files. Medications are kept inside Med-Room inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

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

FACILITY NAME: SALEM SOUTH HOME	FACILITY NUMBER: 366408346
	VISIT DATE: 01/13/2025

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

Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility

Administrator Anna Lopez.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

LIC809 (FAS) - (06/04)

Page: 2 of 2