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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881321
Report Date: 10/09/2024
Date Signed: 10/09/2024 12:29:12 PM

Document Has Been Signed on 10/09/2024 12:29 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CANYON VIEW HOMEFACILITY NUMBER:
361881321
ADMINISTRATOR/
DIRECTOR:		VERMANI, NITINFACILITY TYPE:
740
ADDRESS:9220 OLD RANCH RDTELEPHONE:
(909) 244-0286
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 6DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:12 AM
MET WITH:Sandy Barr, ManagerTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analysts (LPAs) LaVette Farlow and Bernadette Allen arrived unannounced to conduct the required annual visit to the facility. LPAs met with Manager Sandy Barr, and introduced themselves and stated purpose of the visit. LPAs were informed that there was 3 client home and 3 in Innovage day program.

The facility has 4 bedrooms, 2 1/2 bathrooms, 1 staff bedroom, kitchen, dining area, family room, living room, washer and dry in the garage, attached garage, and backyard. LPAs completed a walk through of facility, review of records, and medication.

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 of 74 degrees fahrenheit. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPAs inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 112.1 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher, the last fire extinguisher inspection was conducted 7/2024. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure and inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were observed secure and inaccessible to clients. The facility did not have emergency kits in the facility for clients in care. A technical advisory was issued. There are no firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CANYON VIEW HOME
FACILITY NUMBER: 361881321
VISIT DATE: 10/09/2024
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Yards/Outside: LPAs observed shaded area with table and chairs on patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Record Review: LPAs reviewed Administrator and staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPAs reviewed client files for admissions agreements, pre-admissions appraisals, physician's reports, and care plans. LPAs observed that the manager in the facility was not associated to the facility. A technical advisory was issued.

No deficiencies were cited during this visit, two (2) technical advisories were issued.



An exit interview was conducted where this report LIC809, LIC809C, LIC9102TA and appeal rights were discussed and copies were provided to the Manager Sandy Barr at the end of the visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
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