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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424320
Report Date: 03/28/2023
Date Signed: 03/28/2023 01:10:54 PM

Document Has Been Signed on 03/28/2023 01:10 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:FAUSTINA CARE CENTERFACILITY NUMBER:
366424320
ADMINISTRATOR:RUFINA C. LAYGOFACILITY TYPE:
735
ADDRESS:24888 STANDING ROCK RDTELEPHONE:
(760) 961-0188
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 4DATE:
03/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Rufina LaygoTIME COMPLETED:
01:30 PM
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 Licensing Program Analyst (LPA) Victoria Chitgian arrived unannounced to the facility for a required annual inspection. Facility is an Adult Residential Facility licensed for six (6) ambulatory clients. LPA met with Administrator Rufina Laygo. At the time of the visit, all clients were away at day program.
LPA toured the facility inside and out. Outdoor and indoor passageways were kept free of obstruction. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. 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 the required furniture and functional lighting. 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 2/27/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Cleaning supplies were stored in the storage and laundry areas. Centrally stored medications were kept in a safe and locked cabinet. LPA toured the client bathrooms. LPA measured the hot water temperature in the bathrooms and kitchen. The hot water temperature in the client bathroom measured 114 degrees Fahrenheit. LPA observed the faucet in the client bathroom was loose and not in good repair. Technical Violation issued. LPA observed emergency supplies in the garage. The outside of the facility had a shaded area with a bench and table. The facility does not have bodies of water.
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 reviewed medications. Medications were dispensed appropriately according to the physician's orders. Licensee has secured each consumer’s personal property and cash resources. All required postings were visible in a common area. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2023
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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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: FAUSTINA CARE CENTER
FACILITY NUMBER: 366424320
VISIT DATE: 03/28/2023
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No deficiencies were cited during this visit. One technical violation issued. An exit interview was conducted where this report was discussed and provided to the Administrator Rufina Laygo, at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC809 (FAS) - (06/04)
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