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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412576
Report Date: 12/16/2024
Date Signed: 12/16/2024 12:37:15 PM

Document Has Been Signed on 12/16/2024 12:37 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:ASSISTED LIVING OF AMERICAFACILITY NUMBER:
366412576
ADMINISTRATOR/
DIRECTOR:
VIVIAN M. SMITHFACILITY TYPE:
740
ADDRESS:12956 11TH STREETTELEPHONE:
(909) 795-4886
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Aspe Zenaida-LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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Licensing Program Analysts (LPA) Bernadette Allen made an unannounced visit to the facility to conduct an annual inspection. LPA was greeted by Licensee- Aspe Zenaida who allowed entry into the facility and she was informed of the purpose of the visit.

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 71 degrees. LPA inspected client bedrooms which are equipped with required furniture such as: mattresses, night-stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility.

LPA measured and observed the water temperatures in the bathrooms to be between 105.7 -120 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide detectors. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in main area.

Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients locked under the sink. Medications are are also kept inside a locked cabinet in the kitchen.

Food Service: Non-perishable and perishable food supply is sufficient for the number of clients in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed two (2) client files for admission agreements, physician reports, and needs and services plans. The licensee has a physicians report for Client 1(C1) however it was not signed by their physician. The licensee has agreed and called the physician during the visit to get document signed. Licensee has agreed to email LPA a copy of signed report by 12/23/2024.

LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

Karen ClemonsTELEPHONE: (951) 248-0349
Bernadette AllenTELEPHONE: 951-897-2618
DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ASSISTED LIVING OF AMERICA
FACILITY NUMBER: 366412576
VISIT DATE: 12/16/2024
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Medications were audited at random and appeared to be dispensed appropriately by staff members.

An exit interview was conducted, and this report was discussed and provided to Licensee Aspe Zenaida at the conclusion of the visit with appeal rights.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
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