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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413179
Report Date: 02/07/2024
Date Signed: 02/07/2024 11:18:59 AM

Document Has Been Signed on 02/07/2024 11:18 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: 6DATE:
02/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Francis Pastorfide, Facility ManagerTIME COMPLETED:
11:25 AM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at Alyza Home, Adult Residential Facility; unannounced to conduct an Annual Inspection. LPA was greeted by Facility Manager, Francis Pastorfide and granted entry. LPA introduced self and stated purpose of the visit. LPA was provided a space to work and accompanied by Facility Manager, Francis Pastorfide on a facility tour.

LPA Coleman conducted a tour of the facility, inside and outside, and observed the following:


Facility: The Facility is licensed for six, (6) non-ambulatory Adult Residents. The census at time of the visit was 6, residents were kept home due to the inclement weather. The facility maintains partnership with Inland Regional Center at Level 4I. The facility is operating at the capacity and in the conditions approved by Community Care Licensing (CCL).

Physical Plant: The facility is comprised of four bedrooms, 2 bathrooms, kitchen, 2 living rooms, dining room, laundry room, backyard and attached garage. LPA Coleman observed the facility's interior temperatures to be comfortable. Lighting throughout the facility is was sufficient and provided by various lamps and night-lights in hallways. Ensuring residents can see and move about the facility safely. LPA observed two bathrooms, each bathroom included operable appliances, non-slip grip materials, adequate amounts of paper and hand hygiene supplies. Fire/Smoke and Carbon Monoxide alarms were tested during the visit and found to be in operable condition. LPA observed two, (2) fire extinguishers in the kitchen and hallways. LPA observed both fire extinguishers were last inspected September of 2023 and fully charged. Mr. Pastorfide reports that the facility conducts disaster drills every 6 months and fire drills on a monthly basis. The Laundry Room included a functional washer and dryer. Laundry Detergent and other chemical agents were maintained securely inside the Laundry Room.

Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALYZA HOME
FACILITY NUMBER: 366413179
VISIT DATE: 02/07/2024
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Resident Rooms - Each resident room is shared between two residents in care. Each room included beds with appropriate linens, lighting, seating, in tact windows/screens, trash cans and adequate storage spaces.
Food Service: Nonperishable food items are maintained in a pantry. LPA observed canned goods in good standing, condiments, crackers, chips and various snacks. Perishable food items are maintained in the kitchen refrigerator and in a refrigerator in the garage. The amount of food items is sufficient for number of residents in care. Food is being prepared and stored properly. Facility has a variety of food available as depicted in the facility's monthly food menu. LPA observed a secure drawer and under-sink cabinet which contained the facility's sharp objects and cleaning chemicals/supplies.
Care & Supervision: Facility has a sufficient number care staff on duty; who assist residents 24 hours and 7 days a week as some staff members reside on facility property.
Record Review and Resident/Staff Files: LPA Coleman reviewed records for staff members and confirmed each staff member has updated staff training in areas such as: Medication Management, CPR/1st Aid, Direct Support Provider, Managing People, Incident Reporting, HIPPA, and Resident Rights. Each staff file also included current TB test, Criminal Statements, Fingerprinting and Background Checks. The Administrator's Administrator Certificate was observed in compliance. LPA reviewed resident files and found that they reflected current Physician's Reports, Admissions Agreements, TB Tests, and Needs and Services for each resident in care.
Signs and Posters: LPA observed the following posters throughout the facility: Disaster Plan, Resident Rights, Administrator Certificate, Personal Rights, Facility License, Facility Sketch with evacuation plans, If you SEE SOMETHING SAY SOMETHING, Infection Control, Staff Roster, Labor Laws and Infection Control.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and maintained securely.

No deficiencies were cited during this inspection. Exit interview conducted and copy of this report was reviewed and discussed, then provided to Facility Manager, Francis Pastorfide.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC809 (FAS) - (06/04)
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