331800085-12-5-2023-56-AS-RGAR-CY8SZ5-20231205131833

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800085
Report Date: 12/05/2023
Date Signed: 12/05/2023 01:18:38 PM

Document Has Been Signed on 12/05/2023 01:18 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:	MCCOY ADULT GROUP HOME		FACILITY NUMBER:	331800085
ADMINISTRATOR:	LACY,TORI		FACILITY TYPE:	735
ADDRESS:	1113 GARRETSON AVE		TELEPHONE:	(909) 437-5262
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY: 6		CENSUS: 4	DATE:	12/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Charisse McCoy- Licensee		TIME COMPLETED:	01:28 PM

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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Licensee Charisse McCoy and was granted entry to the facility. At the time of the visit there were two (2) staff present and zero (0) clients present.

The facility is a four (4) bedroom, three (3) bathroom home with a kitchen/dining area, and living room. The facility is an Adult Residential Facility (ARF) level 4i home vendorized by Inland Regional Center. The facility is licensed for a capacity of six (6) clients and the current census is four (4) clients. LPA was accompanied by Licensee 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 the indoor and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathroom to be at 127.7 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 clients in care. There was a designated storage space for client/staff files. Medications are kept inside medication cabinet in the kitchen inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

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

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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: MCCOY ADULT GROUP HOME	FACILITY NUMBER: 331800085
	VISIT DATE: 12/05/2023

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Record Review: LPA reviewed four (4) client files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications/MARs records were audited and appeared to be dispensed appropriately by staff members.

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 Licensee Charisse McCoy.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

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