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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530274
Report Date: 10/02/2024
Date Signed: 10/02/2024 01:36:05 PM

Document Has Been Signed on 10/02/2024 01:36 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:ADORA CARE NORTHFACILITY NUMBER:
365530274
ADMINISTRATOR/
DIRECTOR:		VANG, CHE LIYEFACILITY TYPE:
740
ADDRESS:1028 KIMBERLY AVETELEPHONE:
(909) 894-4234
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 6CENSUS: 0DATE:
10/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Administrator Che Liye VangTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Sarina Ramirez conducted an announced visit to the pending facility for the pre-licensing inspection. LPA met with applicant Che Liye Vang


The pending application is for six (6) bedridden residents in a Residential Care Facility for the Elderly (RCFE). LPA toured the facility inside and out. The following was observed, reviewed, and inspected: there are six (6) bedrooms and three (3) bathrooms. There are no bodies of water. The physical plant, in general, was in good repair. Buildings and grounds are free from hazards. Indoor and outdoor passageways were free of obstruction. There is a charged fire extinguisher, operating smoke alarms, and carbon monoxide detectors. There is a locked area for medications, cleaning supplies, and sharps. LPA observed a working telephone and basic laundry equipment. Resident bedrooms had the required bedding and furniture. Bedrooms had sufficient lighting. LPA measured the hot water temperature in the resident bathrooms and it was 117 and 120 degrees F. The facility had a sufficient amount of linens and hygiene items for the clients. The facility had a sufficient amount of nonperishable and perishable food items. The food was kept in a safe and healthful manner. The facility menu was available for review. The freezer was -6 degrees F. The refrigerator was 40 degrees F. Dishes, glasses, and utensils were in good condition. The facility had a designated area for staff and resident records. Emergency disaster plans, personal rights, and complaint procedures were posted in a common area. The facility was equipped with a complete first aid kit and manual. There is adequate seating in the common areas. Facility had a supply of activities for the clients. Night lights were maintained in the hallways.

Pre-licensing inspection is complete, and no corrections are needed to be made. Facility appears to be ready for licensure An exit interview was conducted where this report was discussed and provided to the applicant Che Liye Vang..

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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