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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424420
Report Date: 05/03/2024
Date Signed: 05/03/2024 02:19:30 PM

Document Has Been Signed on 05/03/2024 02:19 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:FAITH ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
366424420
ADMINISTRATOR/
DIRECTOR:		ALVARADO, FRANCIAFACILITY TYPE:
735
ADDRESS:1660 NARANJO CT.TELEPHONE:
(909) 351-6532
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 4CENSUS: 3DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:Francia Alvarado - LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:25 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
Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required 1-year visit to the facility. LPA met with Francia Alvarado, Licensee, and discussed the purpose of the visit.

The facility is a level (2), Adult Residential Facility (ARF) and is an Inland Regional Center (IRC) certified vendor. LPA conducted an overall inspection of the facility, which included, but was not limited to the following:

Operation/Physical Plant: The facility has a fire clearance for four (4 ) ambulatory clients and a current census of three (3) clients. The facility has a infection control plan and client registry list on file. The facility has no swimming pools or similar bodies of water. The facility also has sufficient backyard activity space for clients in care; However, the facility's backyard has overgrown dry weeds which presents a safety hazard. Deficiency cited.The facility’s indoor passageways were kept free of obstruction. The facility has sufficient indoor activity space and supplies for client use. The facility is maintained at a comfortable temperature. The facility is equipped with operating laundry equipment, carbon monoxide alarms and telephone service. The facility has sufficient supply of bed linen, towels, and hygiene products for clients in care. The facility has posted in a common area client personal rights, facility license, and emergency telephone numbers. Client bedrooms were equipped with beds, bed linen, chairs, storage space and sufficient lighting. Client toilets, hand washing and bathing facilities were operating in safe and sanitary conditions. The hot water in client bathrooms tested at 107 degrees F.

Food Service: The facility has sufficient non-perishable and perishable food for number of clients in care. The facility’s freezer temperature is maintained at zero degrees. The facility’s refrigerator temperature is maintained at 38 degrees F. The facility has sufficient cups, plates, and utensils for client use. Disinfectants and cleaning solutions are kept locked and store away from food areas.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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 6
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: FAITH ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 366424420
VISIT DATE: 05/03/2024
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
Health Related Services: All client medications are labeled and centrally stored in a locked cabinet inaccessible to clients in care. The facility has a first aid kit and manual.

Personnel/Client Records: The Administrator's certification is current. Three (3) staff records audited had health screenings, criminal record clearances, job and first aid/CPR trainings. Three (3) client records had admission’s agreements, medical assessments, needs and service plans, personal and incidental (P&I) logs, and personal rights. LPA observed Client #1(C1) did not have a current annual Needs/Service plan on file. Deficiency Cited.

Based on observations and record review, deficiencies are being cited per Title 22, of The California Code of Regulations.



This report, deficiencies, and correction plans were reviewed with the Licensee and copies with Appeal Rights were provided and the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 05/03/2024 02:19 PM - It Cannot Be Edited


Created By: Magda Malcore On 05/03/2024 at 01:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FAITH ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 366424420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Building and Grounds
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observations the licensee did not comply with the section cited above by the facility's backyard has overgrown dry weeds, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
1
2
3
4
The Licensee shall submit proof of cleared dry weeds in the backyard by POC due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/03/2024 02:19 PM - It Cannot Be Edited


Created By: Magda Malcore On 05/03/2024 at 01:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FAITH ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 366424420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above by not maintaining and annual service plan on file for Client #1, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
1
2
3
4
The Licensee shall submit to the Licensing Agency Client #1's current Service plan by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6