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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411418
Report Date: 11/21/2024
Date Signed: 11/21/2024 01:47:36 PM

Document Has Been Signed on 11/21/2024 01:47 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LOVE & CARE HOMEFACILITY NUMBER:
366411418
ADMINISTRATOR/
DIRECTOR:		DY, ZENAIDA G.FACILITY TYPE:
735
ADDRESS:5475 ARENA WAYTELEPHONE:
(909) 899-1061
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 2DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator Zenaida GTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 11/21/2024 at 11:00 AM, Licensing Program Analyst (LPA) Beena Singh arrived unannounced to conduct the required comprehensive annual visit to the facility. LPA Beena Singh knocked at the facility door and no one was at the facility. LPA Beena Singh phone Administrator Zenaida and she arrived at the facility, met with Licensee/Administrator Zenaida Dy introduced self, and stated the purpose of the visit.

The facility has five (5) bedrooms, three (3) bathrooms, kitchen, dining room, living room, and attached garage. The facility is vendorized by Inland Regional Center. LPA Beena Singh completed a walk through of the facility, review of records, medication audit and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL), LPA Beena Singh observed no clients at the facility as they are out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA Beena Singh inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs, and sufficient lighting. LPA Beena Singh inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 110 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. Sharps and medications were kept in secure cabinets inaccessible to clients. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. Overall, the facility is clean, and operates in safe conditions for clients in care.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LOVE & CARE HOME
FACILITY NUMBER: 366411418
VISIT DATE: 11/21/2024
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Yards/Outside: One shaded patio, one (1) side gate with door knob not lock on the right side of the house that leads into the backyard, and three (3) car attached garage observed. The outdoor pathway on the side of the facility was free of obstructions.

Food Service: LPA Beena Singh observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


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

Record Review: LPA Beena Singh reviewed two (2) client files for admission agreements and needs and services plans, functional capabilities and Physician Report (LIC602). LPA Beena Singh also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, training, and health screenings, no issues observed. LPA Beena Singh reviewed C1 and C2 P&I records and LPA Brown observed no issue. LPA Beena Singh reviewed medications and observed no issues.

An exit interview was conducted where this report LIC809, LIC809C,were discussed, and copies were provided to Licensee/Administrator Zenaida Dy.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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