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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424115
Report Date: 08/28/2024
Date Signed: 08/28/2024 02:43:33 PM

Document Has Been Signed on 08/28/2024 02:43 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/
DIRECTOR:		PEREZ, ELIDAFACILITY TYPE:
735
ADDRESS:12158 STUVELING ST.TELEPHONE:
(760) 947-9426
CITY:OAK HILLSSTATE: CAZIP CODE:
92344
CAPACITY: 4CENSUS: 3DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Elida Perez-LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:53 PM
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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. LPA was informed that all clients in care are in day program.

The facility has 3 client bedrooms with private bathrooms, 1 staff bedroom with private bathroom, 1 additional bathroom, front room, kitchen, dining area, living room, family 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 105 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, CCL complaint poster, emergency disaster plan and facility license were posted in a common area. 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: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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: CASA PEREZ, INC.
FACILITY NUMBER: 366424115
VISIT DATE: 08/28/2024
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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 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed Licensee and staff files 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 July 1, 2024.

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

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

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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