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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881217
Report Date: 11/22/2021
Date Signed: 11/22/2021 11:54:56 AM

Document Has Been Signed on 11/22/2021 11:54 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:HELENA HOMEFACILITY NUMBER:
361881217
ADMINISTRATOR:DELGADO, LORFYFACILITY TYPE:
740
ADDRESS:1395 N SAN ANTONIO AVETELEPHONE:
(818) 621-3537
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 0DATE:
11/22/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lorfy DelgadoTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Melody Brown made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. This visit is announced because this is a relocation from another site. LPA Brown met with Administrator/Applicant Lorfy Delgado and was granted entry. The home will be licensed for a total capacity of (6) non-ambulatory residents in a Residential Care Facility for the Elderly.

LPA Brown took a tour of the interior and exterior of home. The following was observed, reviewed, and inspected: there are four (4) resident bedrooms, one (1) staff bedroom/ office and two (2) resident/staff bathrooms. The physical plant, in general, was in good repair. Buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. The outside of the facility had a shaded area with seating.



There are charged fire extinguisher, operating smoke alarms, and carbon monoxide detectors. The facility has a telephone and per Administrator Delgado, they will transfer the phone line from the other facility. There is a locked area for cleaning supplies, medications, and sharps. LPA Brown toured the bedrooms. Resident bedrooms had the required bedding, furniture, and functional lighting. The facility had a supply of additional linen and extra hygiene items for the residents. LPA Brown toured the kitchen. Food was stored in a safe and healthful manner. The facility had a 2 day supply of perishable food items and 7 day supply of nonperishable food items. The facility menu was available for review. Dishes, glasses, and utensils were in good condition. The facility has a designated area for staff and resident files. LPA Brown toured the resident/staff bathrooms. The bathrooms were operating in safe and sanitary conditions. LPA Brown observed grab bars and non-skid mats. LPA Brown measured the hot water temperature in the kitchen. The hot water temperature measured 118 degrees F. Emergency disaster plans, personal rights, Ombudsman poster, Administrator certificate (to be posted) and Community Care Licensing complaint poster were posted in a prominent area. The facility was equipped with a complete first aid kit (e.g. thermometer, tweezers, scissors, antiseptic, bandages, gauze) including a first aid manual. There is adequate seating in the common areas. Night lights were maintained in the hallways.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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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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
RIVERSIDE, CA 92507
FACILITY NAME: HELENA HOME
FACILITY NUMBER: 361881217
VISIT DATE: 11/22/2021
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The facility had a supply of activities for the residents. Emergency lighting (e.g. flashlights) were also maintained.

Additionally, LPA Brown observe facility to have required single entry point for COVID screening and vaccination verification requirement log upon entering the facility. LPA Brown observed required COVID posting throughout the facility, and soap and paper towels in bathrooms for washing hands. Backyard is fenced and has a shaded area with table and chairs for residents’ use. Backyard passageways were free of obstructions and gate exits to be unlocked. At this time facility has shown to have met pre-licensing requirements.

The following needs to be corrected prior to being licensed: LPA Brown observed damaged screen in one (1) resident bedroom. Applicant/Administrator Delgado acknowledged that it needs to be replaced. Administrator Delgado reported that the screen door will be replaced today. Proof of replaced screen door will be submitted to the Department by 11/24/2021.



An exit interview was conducted where this report was discussed and provided to applicant/Administrator Lorfy Delgado.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
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