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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412378
Report Date: 09/25/2024
Date Signed: 09/25/2024 10:54:52 AM

Document Has Been Signed on 09/25/2024 10:54 AM - 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:CASA DE AMELIA ARFFACILITY NUMBER:
366412378
ADMINISTRATOR/
DIRECTOR:		GLEN A. SMITHFACILITY TYPE:
735
ADDRESS:7650 JADEITE AVETELEPHONE:
(909) 476-1938
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY: 4CENSUS: 3DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Glen Smith, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Becky Mann visited the facility unannounced to complete a comprehensive annual inspection. LPA Mann met with Licensee/Administrator Glen Smith and explained the purpose of the visit. Today’s inspection included a facility tour, record review, and interviews with staff.

The facility is 4 bedrooms and 2 bathrooms. The facility also has kitchen/dining area, living area, covered patio, and attached garage. Licensed capacity is 4, and the facility current census is 3.

Physical Plant: There are no obstructions to indoor and outdoor passageways. LPA Mann inspected resident bedrooms; each room included required furniture such as mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were functional. LPA Mann observed adequate furniture and lighting throughout the facility. The hot water temperature tested at 112.8 degrees Fahrenheit. The facility has operating smoke detectors and carbon monoxide alarms, which LPA Mann tested during the visit. LPA Mann observed personal rights posters, Licensing documents, and the disaster plan posted throughout the facility. LPA Mann observed that cleaning supplies, toxins, sharps, and other dangerous items are kept secure and inaccessible to residents in care. There was a designated storage space for client/staff files. LPA Mann observed medications locked and 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 in number for residents in care. The facility has a variety of food available for clients. Dishes, cups, and utensils were also appropriately stored.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CASA DE AMELIA ARF
FACILITY NUMBER: 366412378
VISIT DATE: 09/25/2024
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Care & Supervision: The facility staff is sufficient in the number of care and supervision of residents in care. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA Mann reviewed 3 client files for admission agreements, updated physician reports, and needs and services plans. Medications were audited randomly and appeared to be dispensed appropriately by staff members. LPA Mann reviewed 4 staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings.

No deficiencies were cited during today's visit. LPA Mann conducted an exit interview with Glen Smith, where a copy of this report was discussed and provided.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
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