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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408649
Report Date: 07/26/2024
Date Signed: 07/26/2024 02:30:49 PM


Document Has Been Signed on 07/26/2024 02:30 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:ALOHA PRIVATE HOME CAREFACILITY NUMBER:
366408649
ADMINISTRATOR:VENDIOLA, HEIDI C.FACILITY TYPE:
740
ADDRESS:24944 TULIP AVENUETELEPHONE:
(909) 796-6965
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 1DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH: Heidi Vendiola-AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst's (LPA's) Bernadette Allen and La Vette Farlow made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Heidi Vendiola, Licensee and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE). Licensed capacity is (6) with a hospice waiver for (2). The current census is one (1). LPA's conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPA's inspected the facility inside and out passageways were kept free of obstruction. The facility has sufficient furniture and activity space for clients in care. The facility has sufficient lighting and is maintained at a comfortable temperature 78 degrees F.

LPA's inspected the kitchen. Facility has sufficient non-perishable and perishable food for the number of clients in care. Facility has a sample menu on file. Sharps are stored and kept locked and inaccessible to clients in care.

LPA's inspected (3) client bedrooms. Bedrooms are equipped with required furniture such as: mattresses, night stands, chairs and storage space. Bedrooms have sufficient linen and lighting.

LPA's inspected (3) client bathrooms. Bathrooms were equipped with handrails and operating in safe and sanitary conditions. Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. LPA's reviewed one (1) client files for admission agreements, updated physician reports, Medication Administrative Record (MAR) and needs and services plans. LPA's reviewed one (1) client medications that appeared to be given to the client as prescribed by their physician. LPA's also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.Based on the observations made during today’s visit, no deficiencies were cited.

An exit interview was conducted, and this report was discussed and provided to Heidi Vendiola administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
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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