331880867-3-20-2023-56-AS-ACON-CQ4Q3Y-20230320114931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880867
Report Date: 03/20/2023
Date Signed: 03/20/2023 11:49:40 AM

Document Has Been Signed on 03/20/2023 11:49 AM - 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:	JANELLE LN ARF		FACILITY NUMBER:	331880867
ADMINISTRATOR:	DOST, HAROON		FACILITY TYPE:	735
ADDRESS:	31058 JANELLE LN		TELEPHONE:	(858) 733-1876
CITY:	WINCHESTER	STATE: CA	ZIP CODE:	92596
CAPACITY: 4		CENSUS: 2	DATE:	03/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Nazifa		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst, Amber Coleman arrived at the Janelle Lane Adult Residential Facility to conduct an Annual Inspection. LPA knocked on the door and was greeted by Nazifa Azizi, Direct Service Provider (DSP) and invited inside. LPA introduced self and stated purpose of the visit. LPA signed in and observed a COVID station along with PPE, hand sanitizer and infection control signs. LPA provided a space in the dining room to work. DSP informed LPA the current census is 2. 2 residents were currently out of the facility during time of visit. LPA contacted Administrator, Haroon Dost to inform of LPA visit and to ask for access to 2 rooms in the facility the DSP had no access to. Administrator agreed to make a visit to facility to provide access to those rooms. LPA's visit consisted of a walk through of the facility, staff interview and file reviews. LPA observed the following:

Resident rooms: LPA observed 4 resident rooms. 2 occupied and 2 vacant. All rooms included appropriate regulated furniture. Mattresses and box spring were in good condition, adequate lighting, plenty of dresser and closet space observed. Wall and floors were clean and in good condition. Bed linens, comforters and bath towels were adequately stocked at time of visit. DSP stated that no staff are currently residing at facility.

Bathrooms - clean, orderly all included paper supplies and hand hygiene supplies. Non- slip grip rugs and strips in the shower. Toilets and water facets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries accessible to clients.

The kitchen area was accessible and free of debris at the time of the inspection. LPA observed the facility has sufficient space for safe operation. Medications and files are centrally stored in a secure cabinet near the rear sliding door. LPA observed secure cabinets for sharp objects and cleaning solutions. Enough food was observed in the refrigerator and pantry. LPA observed food menus posted on the refrigerator along with any changes made to menu. First aid kit and emergency supplies observed in kitchen island in a secure cabinet.

Family rooms included adequate seating, space and activities for the residents in care at this time.

Please see LIC809C**

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

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: JANELLE LN ARF	FACILITY NUMBER: 331880867
	VISIT DATE: 03/20/2023

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LPA verify the background check status of all individuals associated with the facility prior to the visit. Last Fire Drill & Disaster Drill are conducted on a monthly basis. Last fire drill conducted 1/14/23. Fire Extinguisher last inspected 2/2023.

Outside grounds were toured with DSP and LPA observed no bodies of water and no debris. Patio furniture was accessible. Exits/Walkways around the home were free of hazards.

During this visit, no deficiencies were cited under California Code of Regulations Title 22. Exit interview conducted and discussed with Administrator and a copy of this report LIC809 and LIC809C was provided during this visit.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC809 (FAS) - (06/04)

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