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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881183
Report Date: 10/11/2021
Date Signed: 10/11/2021 11:35:48 AM

Document Has Been Signed on 10/11/2021 11:35 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
RIVERSIDE, CA 92507
FACILITY NAME:MIRIAM'S HOMECAREFACILITY NUMBER:
361881183
ADMINISTRATOR:GAD, ENRICOFACILITY TYPE:
740
ADDRESS:1635 HAMPSHIRE RDTELEPHONE:
(818) 912-0178
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92404
CAPACITY: 6CENSUS: 5DATE:
10/11/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Enrico Gad, AdministratorTIME COMPLETED:
11:45 PM
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Licensing Program Analyst (LPA) Jesse Gardner conducted an announced pre-licensing inspection to the facility to complete the pre-licensing inspection and Comp III. LPA arrived at the facility at 10:00 AM and met with Licensee Miriam Nauseda and Administrator Enrico Gad. Upon arrival, LPA's temperature was taken, and LPA signed into the facility. Licensee Nauseda and Administrator Gad accompanied LPA on a tour of the inside and outside of the facility.

Currently there are 5 residents in care. Two rooms are shared by two residents in each. The facility is a five bedroom, two bath home with a living room, dining room, and kitchen. Per the approved fire clearance, the licensee is approved for 5 non-ambulatory residents and 1 ambulatory resident. All bedrooms are furnished with bed, night stand, dressers and have adequate lighting for residents use. The one empty room is also furnished with a chair and a night stand with lamp. The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The bathrooms have grab bars and non-skid mats installed. The water temperature was tested and measured between 112.8 to 119.3 degrees Fahrenheit. The smoke alarms and carbon monoxide alarm were tested and are in operating order. LPA observed one fire extinguisher present in the hallway adjacent to the kitchen area and fully charged. The kitchen was observed to have dishes, silverware and pots and pans. The knives were stored in a locked cabinet in the kitchen. The medications, were in the locked hall closet adjacent from the kitchen. The chemicals are locked in the kitchen under the sink. The client files are stored in the kitchen in a locked cabinet. The backyard was observed to be fully fenced with an unlocked gate. The facility has a jacuzzi that is covered and locked with a key lock. The facility also has a pool that is completely fenced and secured by a combination lock.

Comp III was completed with Administrator Gad, and Licensee Nauseda.

LPA found all facility features to be in compliance and in line with Title 22 Regulations.

An exit interview was conducted and a copy of this report was reviewed with and provided to Licensee Miriam Nauseda.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2021
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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