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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427230
Report Date: 10/31/2024
Date Signed: 10/31/2024 04:53:07 PM

Document Has Been Signed on 10/31/2024 04:53 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:BLOOMINGTON CARE CENTER INCFACILITY NUMBER:
366427230
ADMINISTRATOR/
DIRECTOR:
JUDELSON ENRIQUEZFACILITY TYPE:
735
ADDRESS:17552 MAYWOOD STTELEPHONE:
(909) 421-2006
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY: 6CENSUS: 5DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Almario Quizon-Support Staff TIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA’s) Bernadette Allen and Becky Mann made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPAs met with Almario Quizon-Support staff who assisted with the tour of the facility.

The facility is an Adult Residential Facility (ARF) with license capacity of (4) and a current census of (5). The facility is in process of being vendorized through Inland Regional Center (IRC). LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following:

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. LPAs inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The water was measured at 103.2 degrees.

LPAs observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors, fully charged fire extinguisher, and carbon monoxide detectors. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care.

LPAs observed there was a designated storage space for resident/staff files. Medications are kept locked in in the kitchen cabinet inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care.

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.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: BLOOMINGTON CARE CENTER INC
FACILITY NUMBER: 366427230
VISIT DATE: 10/31/2024
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Record Review: LPAs reviewed two (2) resident files for admission agreements, updated physician reports, and needs and services plans which appeared to be current.

During the visit there were no staff files available for review, but files were delivered to the facility within 45 minutes from Cielita Ravelo who was advised that staff files should be at the facility at all times and she agreed files will remain at the facility in the future..

LPAs reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. The files for staff 1 (S1) and staff 2 (S2) were not complete/current with the required documentation. S1 requires TB Results, and S2 requires a current CPI certification. LPAs issued technical advisory to ensure the files will be complete/ current within 1 week of the visit.

Medications were audited at random and appeared to be dispensed appropriately by staff members.

Based on the observations made during today’s visit, no deficiencies were cited but Technical Advisory notes were made.

An exit interview was conducted, and this report was discussed and provided to Almario Quizon at the conclusion of the visit with appeal rights.

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

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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