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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413179
Report Date: 03/22/2023
Date Signed: 03/22/2023 11:19:37 AM

Document Has Been Signed on 03/22/2023 11:19 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ALYZA HOMEFACILITY NUMBER:
366413179
ADMINISTRATOR:FIGURACION, MARIOFACILITY TYPE:
735
ADDRESS:5062 RODEO STREETTELEPHONE:
(909) 270-3738
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY: 6CENSUS: 5DATE:
03/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Designated Administrator Francis PastorfideTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Victoria Chitgian arrived unannounced to conduct a visit to the facility for a required annual inspection. Facility is an Adult Residential Facility licensed for six (6) cognitively non-ambulatory clients. LPA was greeted and granted entry by the Designated Administrator (DA), Francis Pastorfide at the facility.
LPA conducted a walk-through the facility's interior and exterior. The facility has a charged fire extinguisher, operating fire alarm systems, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review and included nutritious options. LPA toured the client bedrooms. The client bedrooms had functional lighting and required furniture. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 1/28/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Medications were kept in a safe and locked cabinet. Sharps and Cleaning supplies were stored in a secured area. LPA toured the kitchen bathrooms. Hot water temperature was measured in the bathrooms and kitchen and was found within required limits at 109 degrees Fahrenheit. The outside of the facility had a shaded area with seating for client comfort. The facility does not have bodies of water. All required postings were visible in a common area.
LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA inspected client medications. Medications were dispensed appropriately according to the physician's orders. Licensee has secured each consumer’s personal property and cash resources. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care.
No deficiencies were issued during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to the (DA) Francis Pastorfide at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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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