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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881164
Report Date: 10/18/2021
Date Signed: 10/18/2021 11:22:18 AM

Document Has Been Signed on 10/18/2021 11:22 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:RUBIO HOMEFACILITY NUMBER:
331881164
ADMINISTRATOR:RODRIGUEZ, SHAYLAFACILITY TYPE:
735
ADDRESS:51800 AVENIDA RUBIOTELEPHONE:
(909) 659-7404
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY: 4CENSUS: 0DATE:
10/18/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Licensee, John EdgingtonTIME COMPLETED:
11:21 AM
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Licensing Program Analyst (LPA) Elecia Weathersby conducted an in person announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate an Adult Residential Facility was submitted to the Central Applications Unit (CAU) for a total capacity of 4 ambulatory residents and 0 bedridden residents. Fire Clearance was granted 07/19/2021. LPA Weathersby observed the following:

No residents currently occupy the property. Licensee currently occupies property.
Structure: Facility was a single-story house with four (4) resident bedrooms with an on suite half bath (Walk in shower only), and one other resident bathroom (Full), living room, dining area, and kitchen area.
Heating/Cooling System: Central heating and air conditioning systems, set at 73 degrees upon inspection.
Bedrooms: Each resident bedroom will accommodate 1 ambulatory client. All bedrooms were adequately furnished with bed, chair, closets, appropriate linens, adequate lighting, and an operational smoke alarm.
Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper, paper towels and toiletries. Water temperature measured by LPA Weathersby read between 105 F and 120 F.
Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.
Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.
Linens and Hygiene Supplies: An adequate supply of hygiene supplies noted.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Elecia Weathersby
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: RUBIO HOME
FACILITY NUMBER: 331881164
VISIT DATE: 10/18/2021
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***Continued from previous page***

Comp III presentation also completed with Licensee, John Edgington.

Facility noted to have a working phone, appropriate first aid kit available, (2) full fire extinguishers attached on kitchen area wall and laundry area wall, hazardous materials and medications appropriately locked, and facility postings were observed.

No deficiencies noted during the prelicensing inspection. The pending facility was found to be in compliance at this time. LPA Weathersby provided a copy of this report and explained the visit results with Licensee at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Elecia Weathersby
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
LIC809 (FAS) - (06/04)
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