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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425914
Report Date: 11/05/2024
Date Signed: 11/05/2024 02:34:39 PM

Document Has Been Signed on 11/05/2024 02:34 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:JULINDA'S HOME CAREFACILITY NUMBER:
366425914
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, JULINDAFACILITY TYPE:
740
ADDRESS:13945 IVY AVE.TELEPHONE:
(909) 371-0314
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: 0DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:09 PM
MET WITH:Julinda RodriguezTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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Licensing Program Analysts (LPAs) Paola Guerrero and Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPAs met with Facility Administrator Julinda Rodriguez and was granted entry to the facility. At the time of the visit there was one (1) staff present, facility currently has no residents. The facility is a four (4) bedroom, two (2), bathroom home, with a kitchen/dining area, living room, and attached garage. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (6) current census (0). LPAs was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following:

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. LPAs inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. LPAs measured and observed the water temperatures in the bathrooms to be at 111 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care.

Care & Supervision: Facility currently has no residents in care.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: JULINDA'S HOME CARE
FACILITY NUMBER: 366425914
VISIT DATE: 11/05/2024
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Record Review: LPAs reviewed one (1) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Julinda Rodriguez.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
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