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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530117
Report Date: 09/20/2023
Date Signed: 09/20/2023 10:28:43 AM

Document Has Been Signed on 09/20/2023 10:28 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ASSISTED LIVING AND MEMORY CARE BY INSPIRATIONSFACILITY NUMBER:
365530117
ADMINISTRATOR:GARCIA, DOMINICFACILITY TYPE:
740
ADDRESS:1048 LA VAUGHN CIRCLETELEPHONE:
(951) 317-4773
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 6CENSUS: 0DATE:
09/20/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Dominic Garica- AdminstratorTIME COMPLETED:
10:38 AM
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Licensing Program Analyst (LPA) Ryan Gardner conducted an announced visit to complete the Pre-licensing inspection. LPA met with Administrator Dominic Garica for a Residential Care Facility for five (5) non-ambulatory residents and one (1) bedridden resident. The fire clearance was approved by the fire department on 9/7/2023.

The facility has five (5) bedrooms and three (3) bathrooms. There are four (4) resident bedrooms, one (1) staff bedroom, a kitchen, two (2) living areas, one (1) dining area, a laundry room, a backyard, and an attached garage. LPA toured the interior and exterior areas of the facility. The following were inspected:

Resident Bedrooms: All bedrooms have the required bedding and furniture, such as clean mattresses/linen, nightstands, dressers, chairs, and lighting.

Resident Bathrooms: The bathrooms appliances were operating in safe and sanitary condition. The water temperature was measured by LPA, the thermometer read at 108.1 degrees F.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for resident use. Kitchen appliances and countertops were free of debris and in good repair. The refrigerator was measured at 40 degrees F and the freezer was measured at 0 degrees F. Chemicals were locked underneath the kitchen sink. The facility has a posted meal schedule.

Sharps/Medication: The knives, sharps, and location for medications were safely locked and secured.

Common Sitting Areas/Activities: There is adequate seating in the common areas for the residents. The facility has a supply of activities for the residents.

Laundry: Additional chemicals and laundry soap were safely locked in the laundry room.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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 2
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: ASSISTED LIVING AND MEMORY CARE BY INSPIRATIONS
FACILITY NUMBER: 365530117
VISIT DATE: 09/20/2023
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Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies were available for each resident.

Backyard: There are no bodies of water in the backyard. There is a covered area with seating for the all the residents. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There is one (1) charged fire extinguisher in the facility. LPA observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and or ammunition.

Dementia Care: All exterior doors have an alarm system to trigger when a door is opened.

Postings: LPA observed required postings including the visitation polices, emergency/disaster plans, complaint procedures, labor laws, and personal rights.

First aid and working telephone: The facility is equipped with a complete first aid kit and manual. The facility has a working telephone for resident use.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA has determined that the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete, and the facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations.

The required Comp III presentation was completed. An exit interview was conducted, and this report was discussed and provided to Administrator Dominic Garica.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC809 (FAS) - (06/04)
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