<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424115
Report Date: 08/23/2023
Date Signed: 08/23/2023 04:02:14 PM

Document Has Been Signed on 08/23/2023 04:02 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:CASA PEREZ, INC.FACILITY NUMBER:
366424115
ADMINISTRATOR:PEREZ, ELIDAFACILITY TYPE:
735
ADDRESS:12158 STUVELING ST.TELEPHONE:
(760) 947-9426
CITY:OAK HILLSSTATE: CAZIP CODE:
92344
CAPACITY: 4CENSUS: 3DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Elida Perez-LicenseeTIME COMPLETED:
04:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/23/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Licensee, Elida Perez, introduced self and stated purpose of the visit.

The facility has 3 client bedrooms with private bathrooms, 1 staff bedroom with private bathroom, 1 additional bathroom, office, front room, kitchen, dining area, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of facility and review of records.

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 of 77 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 107.8 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, first aid kit and charged fire extinguishers. Posters such as; the personal rights, emergency disaster plan and facility license were posted in a common area. LPA observed that the emergency disaster plan was last reviewed on 01/02/2018. Technical violation issued. Cleaning supplies, toxins, sharps, medication and other dangerous items were kept in a locked closet made inaccessible to clients. There was a designated storage space for client/staff files. The facility had emergency kits in the garage for clients in care. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CASA PEREZ, INC.
FACILITY NUMBER: 366424115
VISIT DATE: 08/23/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Yards/Outside: The back yard has open access without any exiting restrictions. There is one shaded patio and one large industrial container that stores wood inside. All outdoor pathways were free of obstructions.

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. Licensee and spouse reside in the home.

Record Review: LPA reviewed 1 client file for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed Licensee file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I funds were counted at random and matched with the ledger. The facility last conducted a disaster drill on August 2, 2023.

No deficiencies and one technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C and LIC9102TV were discussed and copies were provided to the Licensee, Elida Perez.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3