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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413166
Report Date: 03/27/2023
Date Signed: 03/27/2023 12:17:02 PM

Document Has Been Signed on 03/27/2023 12:17 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:PRECIOUS MOMENTS IFACILITY NUMBER:
366413166
ADMINISTRATOR:DE GUZMAN, RAMON CHITOFACILITY TYPE:
735
ADDRESS:16748 UKIAH STREETTELEPHONE:
(760) 596-0378
CITY:VICTORVILLESTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 6DATE:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:TIME COMPLETED:
12:30 PM
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Licensing Program Analyst, Victoria Chitgian, made a visit to the facility to conduct a required annual licensing inspection. Analyst was granted entry into the facility and met with Ramon De Guzman, Administrator. There were six (6) clients at the facility at the time of the inspection.
Analyst reviewed the facility file prior to the visit. A tour of the facility was conducted inside and out. Administrator is providing each consumer with clean linen in good repair, and sufficient hygiene products for personal use. A comfortable temperature is maintained in the facility at all times. The last disaster drill was conducted on 03/15/23. Hot water temperature measured at 108 degrees F. The facility is stocked with a two (2) day supply of perishable and seven (7) day supply of nonperishable food items. Food is being prepared and stored properly. Utilities and appliances were tested and operational. Smoke alarms and carbon monoxide detectors were tested and functional.

Medications are stored in a locked closet in the hallway and administered according to the label instructions. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care. All staff have a criminal record clearance. Staff present has CPR and first aid certificate available. Administrator has secured each consumer’s personal property and cash resources. Needs and Services Plans are updated as needed and maintained in the consumer’s files. Each consumer file contains a signed Admission Agreement. The Administrator is on the premises a sufficient number of hours to adequately administer the facility in compliance with applicable law and regulation.

The backyard of the facility has a shaded area with an umbrella, table and chairs for client comfort. Activities and games are observed for client leisure.

Based on today’s inspection, no deficiencies were observed at this time in the areas evaluated. An exit interview was conducted and this report was discussed and provided to Administrator Ramon De Guzman at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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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