<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881218
Report Date: 11/01/2021
Date Signed: 11/01/2021 11:44:23 AM

Document Has Been Signed on 11/01/2021 11:44 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:LOAFER'S GATEWAYFACILITY NUMBER:
331881218
ADMINISTRATOR:WALKER SR., ALOAFFACILITY TYPE:
735
ADDRESS:1853 VILLINES AVETELEPHONE:
(657) 549-1466
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY: 4CENSUS: 0DATE:
11/01/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Aloaf Walker Sr.TIME COMPLETED:
11:45 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) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 10:00 AM, LPA met with Licensee/Administrator Aloaf Walker Sr. An initial application to operate a Adult Residential Facilities (ARF) was submitted to the Central Applications Bureau (CAB) on 7/28/2021 for a total capacity of four (4) ambulatory residents and zero (0) bedridden. Fire clearance was granted on 09/24/2021. LPA Delgado observed the following:
Structure:
Facility was a one-story house with four (4) resident bedrooms, one (1) resident bathrooms, living room, den, dining area and kitchen. There was an attached two car garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each resident bedroom #1, #2, #3 and #4 will accommodate any non-ambulatory resident, 4 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
The one (1) resident bathroom has a working toilet, two (2) wash basins, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:20 AM, LPA tested the water temperatures in the resident bathroom. LPA verified water temperature was measured at 113.1 degrees Fahrenheit. Bathroom sink water temperature was measured at 111 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition.
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2021
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: LOAFER'S GATEWAY
FACILITY NUMBER: 331881218
VISIT DATE: 11/01/2021
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
26
27
28
29
30
31
32
(CONTINUED FROM LIC 812)
and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located near the hallway. Laundry detergents and cleaning supplies were observed in laundry room secured in a locked cabinet away from residents.
Living/Family room:
There was a living/den room with adequate seating for all clients and TVs.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinets in the main hallway of the residence.
Yards/Outside:
Patio furniture for outdoor seating is arrange and has an umbrella. There was a gate on the left side of the property with a self-latching from the exterior doors. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the den and the emergency phone numbers were observed in the office and kitchen
General items:
Two (2) fire extinguishers were charged and located in the kitchen and hallway. Seven (7) smoke alarms and one (1) carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the office. First Aid kit with required components, and locked area for medication storage was observed. Safe for P& I monies will be locked and secured in cabinet in office desk. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply observed in the garage. Component III is waived due to Licensee completed Component III on 2/8/2018 for another licensed facility.

Pre-Licensing is complete and this facility has no deficiencies.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2