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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425506
Report Date: 01/08/2025
Date Signed: 01/08/2025 12:59:21 PM

Document Has Been Signed on 01/08/2025 12:59 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:YUCAIPA ADULT DAY CENTERFACILITY NUMBER:
366425506
ADMINISTRATOR/
DIRECTOR:		MURRAY, SHARANFACILITY TYPE:
775
ADDRESS:12980 2ND STREETTELEPHONE:
(909) 790-4012
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 49CENSUS: 38DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Vernon Marasigan -Administrator TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analysts (LPA) Bernadette Allen made an unannounced visit to the facility to conduct a required annual inspection. Upon arrival, LPA met with Vernon Marasigan Administrator and he 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 services 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 and listening to music. The facility contains two offices one being used as the 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 inaccessible to clients. The restrooms were clean,contained 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 drill was conducted on 12/19/2024. Smoke detectors are interconnected and found to be operational when tested. The carbon monoxide detector were operational when tested.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CENTER
FACILITY NUMBER: 366425506
VISIT DATE: 01/08/2025
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The facility administers medication to clients during program hours. LPA inspected client medication and the Medication and Administration Records (MARS) for two (2) clients. 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 Vernon Marasigan Administrator at the conclusion of the visit with appeal rights.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC809 (FAS) - (06/04)
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