331881184-5-25-2022-56-AS-AGOG-CERMZN-20220525100326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881184
Report Date: 05/25/2022
Date Signed: 05/25/2022 10:03:35 AM

Document Has Been Signed on 05/25/2022 10:03 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
, CA 92507

FACILITY NAME:	VIPHEALTH SERVICES, LLC		FACILITY NUMBER:	331881184
ADMINISTRATOR:	SASIS, PRINCE NORRIS		FACILITY TYPE:	740
ADDRESS:	1167 SHADY CREEK DR		TELEPHONE:	(909) 225-3462
CITY:	SAN BERNARDINO	STATE: CA	ZIP CODE:	92407
CAPACITY:	6	CENSUS: 0	DATE:	05/25/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Prince Norris Sasis, Applicant		TIME COMPLETED:	10:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Amy Goldenberg conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate a Adult Residential Facility was submitted to the Central Applications Unit (CAU) on 06/14/2021 for a total capacity of 6 non-ambulatory residents. Fire Clearance was granted 07/09/2021 LPA Goldenberg observed the following: Structure: Facility was a two story house with four six (6) resident bedrooms, two bathrooms, living room, dining area, and kitchen area. Second floor will be office space and not for residents. Heating/Cooling System: Central heating and air conditioning systems. Bedrooms: All bedrooms were adequately furnished with bed, chair, large 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 towels, toilet paper, and toiletries. Water temperature measured by applicant and thermometer read by LPA at 115 degrees F. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans 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.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022

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
, CA 92507

FACILITY NAME: VIPHEALTH SERVICES, LLC	FACILITY NUMBER: 331881184
	VISIT DATE: 05/25/2022

NARRATIVE

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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 linens was available.

Yards/Outside: The back was completed was a patio with adequate covered area for providing shade. There were no obstructions. There were no bodies of water observed anywhere on the property.

Garage: Laundry area with washer and dryer were located inside the home at the garage exit. garage. Laundry detergents and cleaning solutions were secured behind a locked cabinet door. Garage was organized and free of obstructions.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, emergency disaster plan are posted.

General items: The smoke and carbon monoxide detectors were tested and operational. = LPA observed a facility phone and it was verified to be operational by LPA.

LPA reviewed COMPONENT III with the applicant during this Pre Licensing Inspection.

This facility physical plant is prepared for licensure pending clearance of the side yard, removal of side gate lock, and mounting of door alarms. This report was reviewed with and a copy was provided to the applicant.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022

LIC809 (FAS) - (06/04)

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