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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530084
Report Date: 03/20/2023
Date Signed: 03/20/2023 02:48:38 PM

Document Has Been Signed on 03/20/2023 02:48 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CHOSEN CARE ASSISTED LIVING, LLCFACILITY NUMBER:
365530084
ADMINISTRATOR:PINILI-ALLEN, EVAFACILITY TYPE:
740
ADDRESS:1469 N. 13TH ST.TELEPHONE:
(909) 377-5274
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 5DATE:
03/20/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Eva Pinilli-AllenTIME COMPLETED:
02:50 PM
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Licensing Program Analyst, Amber Coleman, arrived at the Chosen Care Assisted Living Facility to conduct a Pre-Licensing Visit for a change of ownership. LPA was greeted by staff member and Administrator Eva Pinilli-Allen. LPA introduced self and stated purpose of the visit. LPA was invited in and had temperature taken and requested to sign in. During, visit residents were observed in a gripping game of dominoes with staff. Administrator reports the current census is 5 - no concerns for COVID at this time. LPA provided space to work in the facility's lobby area and began a walk through of the premises. LPA observed the following:

Structure: Facility was a one story house with four resident bedrooms, two bathrooms, living room, family/recreation room, dining area, kitchen and an attached two car garage.

Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Panel secure with plastic cover.

Bedrooms: Each resident bedroom will accommodate any non-ambulatory resident, including a bedridden resident. All resident bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. Each bedroom also included secure night stands for the residents hygiene supplies.
Bathrooms: Both bathrooms have a functional toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Hand rails were observed near toilets and in showers/tubs.
Laundry: Located in the facility's garage. Secure cabinets located above the washer and dryer held laundry detergents. Also included in the garage was additional storage room. Emergency supply of water and extra food supplies. Garage also contained another stocked refrigerator and deep freezer.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CHOSEN CARE ASSISTED LIVING, LLC
FACILITY NUMBER: 365530084
VISIT DATE: 03/20/2023
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Kitchen: 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 well stocked with sufficient perishable food. There was adequate seating for meals. Laundry area with washer and dryer were located near the garage exit.
Living/Family room: There were two separate living/family areas with safe and adequate seating and furnishings are in good repair. Activity supplies located in entertainment centers accessible to residents and guests.
Linens and Hygiene Supplies: An adequate supply of linens was available in each resident room.

Yards/Outside: The back was completed was a patio with adequate covered area for providing shade. There were no obstructions. The backyard does contain a covered hot tub. Hot tub was observed to have padded top made secure with locking mechanism. Administrator also reports there is no water inside the hot tub at this time.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, Ombudsman poster and rights to resident and family councils posters are posted at the front entrance to facility. Personal rights were posted. Facility exit plan posted throughout facility.
General items: The facility has smoke alarms and carbon monoxide detectors. Last fire drill 3/16/23. Not tested due to recent fire inspection and resident sleep during visit. Emergency night lights present. Resident records storage space in the kitchen above the pantry in secure cabinet. Files are also kept in lobby of facility near main entrance. Staff and resident files reviewed and included required complete documents. LPA observed a facility phone and it was verified to be operational.

The facility was evaluated in accordance with the CCR, Title 22 California Code of Regulations. Based on the observations and evaluation of the facility this date, the facility’s ready for licensure. Care tool utilized.

An exit interview was conducted, and a copy of this report LIC809 and LIC809C was discussed and provided with Applicant/Administrator.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC809 (FAS) - (06/04)
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