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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881230
Report Date: 12/10/2021
Date Signed: 12/10/2021 11:01:39 AM

Document Has Been Signed on 12/10/2021 11:01 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:JNJ MAPLE RESIDENTIAL CAREFACILITY NUMBER:
331881230
ADMINISTRATOR:JABONERO, JANICEFACILITY TYPE:
735
ADDRESS:26480 MAPLERIDGE WAYTELEPHONE:
(714) 271-7290
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 0DATE:
12/10/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Janice Jabonero, AdministratorTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Tricia Danielson conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA met with Administrator Janice Jabonero. An initial application to operate an Adult Residential Facility (ARF) was received by the Central Applications Bureau (CAB) on 09/19/21 for a total capacity of four (4) ambulatory clients. Fire Clearance was granted for four (4) ambulatory clients on 10/07/21. LPA Danielson observed the following:
Structure:
Facility was a one story house with four (4) client bedrooms, two (2) bathrooms, living room, family room, 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 client bedroom will accommodate any ambulatory client. All client bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm/carbon monoxide detector.
Bathrooms:
Both bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper, and soap. At 10:15 AM, LPA began testing water temperatures in client bathrooms. LPA verified water temperatures were measured at 110.6 and 109.4 degrees Fahrenheit.
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 drawer and cabinet. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition
(CONTINUED ON LIC 812C)
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021
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: JNJ MAPLE RESIDENTIAL CARE
FACILITY NUMBER: 331881230
VISIT DATE: 12/10/2021
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(CONTINUED FROM LIC 812)
and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry area with washer and dryer were located in a separate room.
Living/Family room:
There was a living and family room with safe and adequate seating for all clients as well as working TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in each client room.
Yards/Outside:
There was a patio with adequate covered seating for all clients. Fencing secured the entire backyard. All outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property.
Garage:
Garage was free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Let-Us-No poster, activity calendar, emergency phone numbers, facility sketch, personal rights were posted in the entry way and hallway.
General items:
Fire extinguisher was charged and mounted in the living room. Smoke alarms/carbon monoxide detectors were tested and were in working order. Flashlights for use in the event of an emergency were available. Client records will be stored in a locked closet. First Aid kit with required components, and locked area for medication storage was observed. There were no firearms or ammunition observed at the facility and LPA was informed the facility will not store firearms or ammunition on the premises.

Component III was waived as it has been previously completed at Licensee's sister facility JNJ Residential Care on July 19, 2018. Pre-Licensing is complete and this facility has no deficiencies. The license will be granted based on final review by and approval from the Central Applications Bureau. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC809 (FAS) - (06/04)
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