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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881288
Report Date: 06/17/2022
Date Signed: 06/17/2022 02:38:44 PM

Document Has Been Signed on 06/17/2022 02:38 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:IRA CAREFACILITY NUMBER:
361881288
ADMINISTRATOR:FORMELOZA, ROWENAFACILITY TYPE:
740
ADDRESS:1598 BRENTWOOD AVETELEPHONE:
(909) 527-5757
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 4DATE:
06/17/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Rowena Formeloza, ApplicantTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Amy Goldenberg 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 (RCFE) was submitted to the Central Applications Unit (CAU) on 03/08/2022 for a total capacity of 6 non-ambulatory residents. Fire Clearance was granted 12/21/2021 This facility is a change of ownership. There are 4 residents currently in care. LPA met with applicant Rowena Formeloza. LPA Goldenberg observed the following:

Structure: Facility was a single story house with four (4) resident bedrooms, two bathrooms, living room, dining area, and kitchen area.

Heating/Cooling System: Central heating and air conditioning systems. Facility is maintained at a comfortable temperature.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by applicant and thermometer read by LPA at 105 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 drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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: IRA CARE
FACILITY NUMBER: 361881288
VISIT DATE: 06/17/2022
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Bedrooms: All bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm.

Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.

Linens and Hygiene Supplies: An adequate supply of linens was available.

Yards/Outside: The back was completed was a patio with adequate covered area for providing shade. There were no obstructions. There is a spa secured with a fence meeting the regulation requirements.

Garage: Laundry area with washer and dryer were located in the garage. Laundry detergents and cleaning solutions were secured behind a locked cabinet door. Garage was organized and free of obstructions.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, Ombudsman poster and clients rights are posted, COVID-19 and hand washing postings. Visitor screening and sin procedures in place.

General items: Smoke detectors and carbon monoxide detectors tested and working. LPA observed a facility phone and it was verified to be operational by LPA.

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

This facility physical plant is prepared for licensure at this time.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
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