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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425506
Report Date: 12/12/2023
Date Signed: 01/31/2024 09:24:59 AM

Document Has Been Signed on 01/31/2024 09:24 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:YUCAIPA ADULT DAY CENTERFACILITY NUMBER:
366425506
ADMINISTRATOR:MURRAY, SHARANFACILITY TYPE:
775
ADDRESS:12980 2ND STREETTELEPHONE:
(909) 790-4012
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 49CENSUS: 34DATE:
12/12/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Annalisa Sialana-Assistant AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analysts (LPA) Bernadette Allen made an unannounced visit to the facility for the purpose of conducting a required annual inspection. Upon arrival, LPA met with Annalisa Sialana, the facility's acting administrator who was informed of the purpose of the visit. The facility is licensed to provide care and supervision for up to 49 clients of which 30 may be non-ambulatory. The program serves clients with developmental disabilities and behavioral issues. The facility is a licensed vendor of the Inland Regional Center.
LPA toured the facility inside and out and walkways/hallways were free of obstruction. The facility is a one-story building consisting of one large community room that is shared by clients. At the time of visit, LPA observed clients participating in activities. The facility contains two offices (one being a nurse office), staff break room, kitchen area, two restrooms, changing room and laundry room. Lunch and snacks are provided to clients during program hours. LPA observed perishable and non-perishable food items stored in a safe manner. All chemicals and toxins are stored in the utility room and were observed to be locked and inaccessible to clients. Carbon monoxide detector was operational when tested. Each restroom was clean, containing toilet paper, paper towels and soap. Hot water temperature was taken and measured at 108 degrees. Fire extinguisher was inspected and found to be fully charged. Disaster drills were conducted on 10/19/2023. Smoke detectors are interconnected and found to be operational when tested.
The facility administers medication to clients during program hours. LPA inspected client medication and the Medication and Administration Records (MARS) for one client. Medications appear to be dispensed per physician's order. First aid kit was observed to be fully stocked.

LPA reviewed staff and client records. All records appear to be current and up to date. Staff files had the required training, updated first aid certification and criminal record clearances. Client files had updated physician statements, ISP's and signed admission agreements.

Based on today's observations, file review and interviews conducted there were no deficiency cited. A copy of the report was discussed and provided to Annalisa Sialana at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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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