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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530001
Report Date: 06/23/2022
Date Signed: 06/23/2022 02:09:24 PM

Document Has Been Signed on 06/23/2022 02:09 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:BEBING HOME CAREFACILITY NUMBER:
365530001
ADMINISTRATOR:ZAPANTA, MAX M.FACILITY TYPE:
740
ADDRESS:17446 MADRONE STREETTELEPHONE:
(909) 574-6832
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 6CENSUS: 5DATE:
06/23/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator/Applicant Max ZaoantaTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Melody Brown conducted an announced visit to the facility 06/23/2022 for the purpose of a Change of Ownership evaluation. At approximately 11:O0 AM, LPA met with Administrator/Applicant Max Zapanta. An initial application for Change of Ownership to operate a Residential Care for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 03/01/2022 for a total capacity of six (6) non-ambulatory residents. Fire clearance was granted on 04/18/2022 for six (6) non-ambulatory residents. LPA Brown observed the following:

Structure:
Facility was a one-story house with four (3) resident bedrooms, one (1) staff bedroom, one (1) resident bathroom and one (1) staff bathroom, living room, den, dining area and kitchen. There was an attached two (2) car garage in the right side of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control the entire house.
Bedrooms:
Each resident bedrooms accommodate any non-ambulatory resident. LPA Brown observed all resident bedrooms were adequately furnished with bed, closet, appropriate linens, adequate lighting, and an operable smoke alarm. However, LPA Brown observed only (three) dressers, three (3) reading lamps and four (4) chairs.
Bathrooms:
The one (1) resident bathroom and one (1) staff bathroom have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. At 01:15 PM, LPA Brown tested the water temperature in the resident bathroom. LPA Brown verified water temperature was measured at 113 degrees Fahrenheit.

***CONTINUED ON LIC 809-C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
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: BEBING HOME CARE
FACILITY NUMBER: 365530001
VISIT DATE: 06/23/2022
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***CONTINUED FROM LIC 809***
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA Brown observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all residents. Laundry room with washer and dryer was adjacent to the hallway. Laundry detergents and cleaning supplies were observed in the garage, garage door is locked away from residents.

Living/Family room:
There was a living/family room with adequate seating for all residents and a working TV.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.

Yards/Outside:
Patio furniture for outdoor seating observed. Self-latching handle on left side of the house that leads into the backyard. LPA Brown observed tons of used clothes, recyclable, multiple large bins on outdoor pathways.

Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the hallway leading to the residents bedroom. There were Ombudsman poster, and Emergency Disaster Plan posted. However, no Let-Us-No poster was observed.

General items:
Three (3) fire extinguisher were charged and located in the office area/den, kitchen and garage, six (6) smoke alarms and one (1) carbon monoxide detector were tested and were observed to be in working order. Resident records were stored in a locked cabinet in the office area/den. First Aid kit with required components, and locked area for medication storage was observed but no First Aid book/Manual at the facility. LPA Brown observed a facility phone and was operational as evidenced by LPA Brown dialing the number. The phone number designated for the facility is 909-574-6832.
***CONTINUED ON LIC 809-C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
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: BEBING HOME CARE
FACILITY NUMBER: 365530001
VISIT DATE: 06/23/2022
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***CONTINUED FROM LIC 809***
There is enough Emergency water supply observed and the required 72-hour emergency food supply was discernible from the regular food supply. Component III was completed on this day as well.

Additionally, LPA Brown observed facility to have required single entry point for COVID-19screening, upon entering facility. LPA Brown observed required COVID signages throughout the facility but no Visitation Vaccination Verification Log and Sign-in Sheet with Covid-19 Symptom Questionnaire Log. LP{A Brown observed soap and paper towels in bathrooms for washing hands. LPA Brown observed activities for the residents such as books and games.

Pre-Licensing is incomplete and the following deficiencies to be resolved by 07//15/2022 at 10:00 AM:

Obtain and post a Let-Us-No poster
Remove tons of used clothes, recyclable, multiple large bins on outdoor pathways.
Obtain First Aid Book/Manual
Post Visitor Policy Procedure and Visitor Policy Door Signs
Covid-19 Symptoms Questions Logs
Visitor Vaccination Verification Log

A follow up Pre-Licensure LIC809 will be generated upon resolution of deficiencies.

An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator/Applicant Max Zapanta.


SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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