331880621-5-18-2023-56-AS-MMAE-CRXU2X-20230518151241

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880621
Report Date: 05/18/2023
Date Signed: 05/18/2023 03:12:51 PM

Document Has Been Signed on 05/18/2023 03:12 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:	FAMILY LEGACY RESIDENTIAL FACILITY		FACILITY NUMBER:	331880621
ADMINISTRATOR:	BADER, IVY T		FACILITY TYPE:	735
ADDRESS:	34847 MIDDLECOFF CT		TELEPHONE:	(949) 413-0891
CITY:	BEAUMONT	STATE: CA	ZIP CODE:	92223
CAPACITY: 4		CENSUS: 2	DATE:	05/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Ivy Bader, Licensee		TIME COMPLETED:	03:20 PM

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Licensing Program Analysts (LPA) Magda Malcore made an unannounced visit to the facility to conduct required annual inspection. LPA met with Ivy Bader, Licensee and discussed the purpose of the visit. At the time of the visit there were two (2) staff at the facility and no clients present. Clients were at the Day Program.

The facility is an Adult Residential Facility (ARF), licensed for four (4) ambulatory clients. The facility has kitchen/dining area, living room, family room and attached garage. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPA inspected the facility inside and out. Indoor and outdoor passageways were kept free of obstruction. The facility has sufficient furniture for clients in care. The facility has sufficient lighting and is maintained at a comfortable temperature of 71 degrees F.

LPA inspected the kitchen. Facility has sufficient non-perishable and perishable food for number of clients in care. Facility has a menus posted on the refrigerator. Facility food is stored in a safe and healthful manner. Sharps and firearms are stored and kept locked and inaccessible to clients in care.

LPA inspected client bedrooms. Bedrooms are equipped with required furniture such as: mattresses, nightstands and storage space. Bedrooms have sufficient linen and lighting. Extra linen stored in hallway cabinets.

LPA inspected the bathrooms. Bathrooms were operating in a safe and sanitary conditions. The hot water temperature tested within regulation at 109 degrees F.

LPA observed the facility is equipped with operating carbon monoxide alarms and fully charged fire extinguishers. Posters such as personal rights, Complaint reporting, facility sketch, the disaster plan were posted in a common area. Cleaning supplies, toxins, items were kept locked and inaccessible to clients in care. Laundry equipment maintained in good condition.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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: FAMILY LEGACY RESIDENTIAL FACILITY	FACILITY NUMBER: 331880621
	VISIT DATE: 05/18/2023

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LPA observed medications are kept in a safe and locked cabinet inaccessible to clients in care. Facility has a complete first aid kit and emergency supplies.

LPAs reviewed two (2) client files for admission agreements, updated physician reports, needs and services plans, all had the required documentation. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings, all had the required documentation. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

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

An exit interview was conducted, where this report (LIC809) was discussed and a copy of report with appeal rights was provided to Licensee at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

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