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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881165
Report Date: 08/16/2021
Date Signed: 09/10/2021 02:33:03 PM

Document Has Been Signed on 09/10/2021 02:33 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DNM WOLLYLEAFFACILITY NUMBER:
331881165
ADMINISTRATOR:MILES, WILTONFACILITY TYPE:
735
ADDRESS:3013 WOLLYLEAF CTTELEPHONE:
(951) 563-5230
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 4CENSUS: 0DATE:
08/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Wilton Miles, AdministratorTIME COMPLETED:
10:35 AM
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***Due to technical difficulties, the Type of Visit could not be indicated as a Pre-licensing visit on the original report issued. This is an exact copy:

Licensing Program Analyst (LPA), Stephanie Torres, conducted an announced pre-licensing inspection at the facility. The LPA met with Licensees, Wilton Miles and Don Jobe. There are currently no clients in care.

Application: The application is for a new Adult Residential Facility (ARF). The fire clearance has been granted for four (4) ambulatory clients.

Buildings and Grounds: The home is composed of four (4) client bedrooms, one (1) staff room/office, two (2) sitting rooms, three and a half (3 1/2) bathrooms, a laundry area, kitchen and dining areas (2), garage, and front/back yard areas. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Miles, there are no weapons stored in the home. Rooms, furniture, beds, mattresses appeared to be in good repair. The bedrooms are fully furnished, and privacy is available. The dining and living room areas are clutter free and in good condition. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer are available and in working order.

Storage and Supplies: Medications will be stored in a locked hall closet, inaccessible to any unauthorized individuals. Secured areas are available for facility files and client files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away in a secured kitchen cabinet. Linens, and equipment appeared to be in good repair and sufficient for the approved census. Fire extinguishers were available and fully charged.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DNM WOLLYLEAF
FACILITY NUMBER: 331881165
VISIT DATE: 08/16/2021
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in working order. Sharps will be stored in a locked kitchen cabinet, available only to authorized individuals.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E), Personal Rights, Facility Sketch (LIC 999), Complaint Poster, Labor Law information, and Visitors Policy.

No needed corrections were observed at time of visit. The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensure. This report was discussed with and a copy provided to the Licensees.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
LIC809 (FAS) - (06/04)
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