360911449-9-5-2024-56-AS-BALN-D8TS4Z-20240905133335

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 360911449
Report Date: 09/05/2024
Date Signed: 09/05/2024 01:33:46 PM

Document Has Been Signed on 09/05/2024 01:33 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:	ST. JOSEPH'S HOME		FACILITY NUMBER:	360911449
ADMINISTRATOR/ DIRECTOR:	RODRIGUEZ, JOSEPHINE F.		FACILITY TYPE:	740
ADDRESS:	2496 1/2 MACY STREET		TELEPHONE:	(909) 887-5884
CITY:	SAN BERNARDINO	STATE: CA	ZIP CODE:	92407
CAPACITY: 8		CENSUS: 6	DATE:	09/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Josephine Rodriguez-Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

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Licensing Program Analyst (LPA's) Bernadette Allen and Becky Mann made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection LPA's met with Josephine Rodriguez-Administrator

At the time of the visit there was two (2) staff present, two (2) clients present and four (4) clients were attending Day Program.

The facility has four (4) bedrooms and four (4) bathrooms a kitchen/dining area, living room. LPA's were accompanied by Facility Administrator, to conduct a general overall inspection, 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. LPA's inspected clients 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.

LPA's observed sufficient furniture and lighting throughout the facility. LPA's measured and observed the water temperatures in the bathrooms to be at 105.2-111 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide detectors. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in the open office area.

Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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: ST. JOSEPH'S HOME	FACILITY NUMBER: 360911449
	VISIT DATE: 09/05/2024

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Food Service: Non-perishable and perishable food supply are sufficient for number of clients 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.

Record Review: LPA's reviewed two (2) client files for admission agreements, updated physician reports, and needs and services plans. The residents files were missing/not current as required by CCL a technical advisory has been issued requiring the clients files to be updated. The administrator was also provided the entrance checklist LIC9123. The licensee has also agreed to update all clients files with their updated physicians reports and MARS for 2024.

LPA's also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screening and all appeared to be current.

Medications are locked inside the closet in the main entrance area.

Overall, the facility is clean, in good repair, and operating in safe conditions for clients..

An exit interview was conducted where this report was discussed and provided to Josephine Rodriguez- Administrator at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

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