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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427230
Report Date: 04/11/2023
Date Signed: 04/11/2023 12:44:20 PM

Document Has Been Signed on 04/11/2023 12:44 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:JUDELSON ENRIQUEZFACILITY TYPE:
735
ADDRESS:17552 MAYWOOD STTELEPHONE:
(909) 421-2006
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY: 6CENSUS: 4DATE:
04/11/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Cielita Ravelo- Staff TIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bernadette Allen met with staff member Cielita Ravelo at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 04/11/2023 at 12:05 PM to initiate a Case Management Office Visit.

LPA Allen requested that the Cielita Ravelo come to the office to sign an amended complaint investigation control number 56-AS-20230314095023 that was conducted on 4/7/2023 and during the visit LPA identified (3) three staff members who were not associated to the facility at the time of the visit.

This poses an immediate Health and Safety risk to those in care. The licensee was cited and Cielita was provided the LIC809, 809-D, and LIC421-BG with the appeal rights at the conclusion of the visit.

An exit interview was conducted where this report was discussed and a copy of the report was provided to Cielita Ravelo at the conclusion of the visit..

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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Document Has Been Signed on 04/11/2023 12:44 PM - It Cannot Be Edited


Created By: Bernadette Allen On 04/10/2023 at 04:57 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
, CA 92507

FACILITY NAME: BLOOMINGTON CARE CENTER INC
FACILITY NUMBER: 366427230

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2023
Section Cited
HSC
80065(i)(2)

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80065 Personnel Requirements
(i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(2) Request a transfer of a criminal record clearance as specified in Section 80019(f)This requirement is not met as evidenced by:
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The licenss has agreed to make sure that staff members (S1,S2, and S3) are associated to the faciliy by using the Guardian System and licensee will provide LPA with confirmation(copy) of association by the POC date of 4/12/2023.
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The licensee did not ensure that the request for transer of criminal record was processed prior to staff (S1,S2, and S3) working at the faciliity.
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Licensee will also provide a statement of understanding of the cited health and safety code.

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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:Bernadette Allen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
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