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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880849
Report Date: 05/10/2023
Date Signed: 05/10/2023 01:04:31 PM

Document Has Been Signed on 05/10/2023 01:04 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:MARC EWELL ARF HOMEFACILITY NUMBER:
331880849
ADMINISTRATOR:EWELL, MARCFACILITY TYPE:
735
ADDRESS:35569 CHANTILLY CTTELEPHONE:
(404) 786-6793
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 4CENSUS: DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Dave, Staff MemberTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Amber Coleman (LPA) arrived at the Marc Ewell Adult Residential Facility. LPA knocked on the door and was met and greeted by Staff Member, Dave Dimauro. LPA was invited inside and requested to sign in. LPA was then provided a space to work. The current census at the time of the visit, was one (1) Mr. Dimauro reported the remaining 3 residents were at their prospective day programs.

LPA conducted a tour of the facility, inside and outside, and observed the following:
Facility: The Facility is licensed for four (4) ambulatory adults, ages 18 -59. LPA observed the facility is operating in the capacity and conditions approved by Community Care Licensing (CCL).
Physical Plant: The facility is a two story residence with an attached "Next Gen" Apartment style add on. Mr. Dimauro reported access to the Next Gen is restricted and secured to staff only. The Next Gen also contains an office which is used as a staff office. It houses chemicals, additional storage for food purchased in bulk, staff and resident files. Lastly, medications are kept secure in the office as well. LPA observed the facility's temperatures to be comfortable at 70 degrees F. Water tested and found to be within regulation. Showers and toilets were found functional. Linens and hygiene items are appropriate for the each resident in care. Each room is equipped with lamps, night-lights and sufficient lighting to ensure residents comfort and safety. The facility is equipped with smoke alarms, carbon monoxide detectors and are operable, and the facility was recently inspected by the Fire Department on 1/18/23, it was determined that residents, fire/smoke/carbon alarms were safe and operating as required. LPA reviewed the facility's Emergency Disaster Plan and Fire Drills and observed that the facility last conducted a Fire Drill on 4/24/23. Last Earthquake Drill was on 3/29/23. Fire extinguishers last inspected 1/18/23.
Food Service: Nonperishable and perishable food is sufficient for number of residents in care. Food is being prepared, stored, and labeled properly. Facility has a wide variety of food available to its residents.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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: MARC EWELL ARF HOME
FACILITY NUMBER: 331880849
VISIT DATE: 05/10/2023
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Care & Supervision: Facility has sufficient care staff. LPA additionally reviewed a staff file and confirmed that staff records reflect current CPR/First Aid Certification and Criminal Record Clearance.
Record Review and Resident/Staff Files: LPA reviewed records for all four (4) residents currently living at the facility. Resident records are complete with updated physician reports and Needs and Services Plans.
Administration: Disaster Plan, Ombudsman poster, Administrator Certificate, and facility license are posted in the hallway of the facility on a cork board on the second floor. Emergency Disaster Plan is current.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and locked in a file cabinet in the office. LPA reviewed all the residents' medications and compared it to the facility's Medication Administration Report (MARs) and Centrally Stored Medication Log. LPA did not observe any medication discrepancies.

No deficiencies were cited during this inspection. Exit interview conducted and copy of this report was provided to Facility Representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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