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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530248
Report Date: 07/18/2024
Date Signed: 07/18/2024 11:33:41 AM

Document Has Been Signed on 07/18/2024 11:33 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:EARLY BIRD CARE HOME 2FACILITY NUMBER:
335530248
ADMINISTRATOR/
DIRECTOR:		CHANTHARASETH, PATSARAFACILITY TYPE:
740
ADDRESS:11949 TRIBUTARY WAYTELEPHONE:
(657) 722-9269
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
91752
CAPACITY: 6CENSUS: 0DATE:
07/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Patsara Chantharaseth-Administrator TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An initial application to operate a Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 05/21/2024 for a total capacity of 6 non-ambulatory. Fire Clearance was granted 06/20/2024. LPA Allen met with Patsara Chantharaseth- Administrator. LPA Allen observed the following:

Structure: Facility was a single story house with five (5) bedrooms, three (3) bathrooms, living room, dining area, office space, and kitchen area.

Heating/Cooling System: Central heating and air conditioning systems.

Bedrooms: All bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm and fire extinguishers.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured at 118 F.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and/or drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition. There was adequate seating for meals.

Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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: EARLY BIRD CARE HOME 2
FACILITY NUMBER: 335530248
VISIT DATE: 07/18/2024
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Linens and Hygiene Supplies: An adequate supply of linens was available. Laundry detergents and cleaning solutions were secured.

Yards/Outside: There was a covered area with adequate seating for staff and clients. There were no obstructions. There were no bodies of water observed anywhere on the property.

Garage: Garage was organized and free of obstructions.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster and clients rights are posted.

General items: LPA observed a working facility phone.

LPA reviewed COMPONENT III with the applicant during this Pre Licensing Inspection.

This facility physical plant is prepared for licensure at this time. A copy of this report was discussed and provided to Patsara Chantharaseth- Administrator at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
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