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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366410695
Report Date: 10/05/2023
Date Signed: 10/05/2023 12:05:06 PM


Document Has Been Signed on 10/05/2023 12:05 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:EVERETT FOREST,LLCFACILITY NUMBER:
366410695
ADMINISTRATOR:ANGELO GALASINAOFACILITY TYPE:
740
ADDRESS:11350 POPLAR STTELEPHONE:
(909) 799-3170
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 6DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH: Angelo Galasinao, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Angelo Galasinao, Administrator, and discussed the purpose of the visit.
The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) with a current census of (6) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:
LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Facility has no outdoor bodies of water. Facility backyard is enclosed with self-latching gates and covered patio is sufficient for outdoor resident activities.
LPA inspected the kitchen. The refrigerator and freezer are operating in a healthful manner. Hot water temperature is maintained at 105 degrees F. Facility has sufficient non-perishable and perishable food supply for residents in care. Facility has sufficient cups, plates, and utensils for residents use. Facility food is stored in a safe and healthful manner.
LPA inspected resident bedrooms. Bedrooms are equipped with beds, bed linen, nightstands, chairs, storage space, and sufficient lighting.
LPA inspected resident bathrooms. Bathrooms are equipment with non-skid mats and grab rails. The hot water temperature in bathrooms tested between 106 and 107 degrees F.
LPA observed the facility is equipped with operating carbon monoxide alarms and telephone service.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EVERETT FOREST,LLC
FACILITY NUMBER: 366410695
VISIT DATE: 10/05/2023
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LPA observed the following posted in a common area: Licensing complaint contact, Ombudsman contact, disaster and evacuation plan. A fire drill was conducted on 9/4/23. Facility has a complete first aid kit. Facility has sufficient linen, emergency supplies, and personal hygiene products for clients. Sharps, disinfectants, cleaning solutions, and toxins are kept in a locked cabinet.
LPA observed resident medications are kept in a locked cabinet inaccessible to residents in care. All medications are labeled and administered as prescribed.
All staff files reviewed had first aid certifications, fingerprint clearances/exemptions, health screenings, training, and personnel records.
All residents files reviewed had admissions agreements, physician's reports, preadmission assessments, and emergency contacts.
An exit interview was conducted, where this report was discussed and a copy of report with appeal rights was provided to the Administrator at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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