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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881257
Report Date: 07/27/2022
Date Signed: 07/27/2022 10:11:08 AM

Document Has Been Signed on 07/27/2022 10:11 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:OSLO HOMEFACILITY NUMBER:
331881257
ADMINISTRATOR:CLOYD, SHILOHFACILITY TYPE:
735
ADDRESS:3678 OSLO CTTELEPHONE:
(619) 292-9299
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 4CENSUS: 0DATE:
07/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Shiloh Cloyd, AdministratorTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Jesse Gardner conducted an announced pre-licensing inspection to the facility to complete the pre-licensing inspection and Comp III. Upon arrival, LPA met with Administrator Shiloh Cloyd. Administrator Cloyd accompanied LPA on a tour of the inside and outside of the facility.

Currently there are no residents in care. The facility is a 4 bedroom, 2 bathroom home with a living room and kitchen. Per the approved fire clearance, the licensee is approved for 4 ambulatory residents. All bedrooms are furnished with bed, night stand, dressers and have adequate lighting for residents use.

The facility currently has paper towels in the restrooms, linens, towels and a sufficient amount of hygiene products for residents. The water temperature was tested and measured between 118.0-119.8 degrees Fahrenheit. The smoke alarms and carbon monoxide alarm were tested and are in operating order. LPA observed a fully charged fire extinguisher which was present in the kitchen/living room area. The kitchen was observed to have dishes, silverware and pots and pans. The medications, will be stored with the knives in a locked cabinet in the kitchen. The chemicals will be stored in a locked cabinet in the hallway.

The backyard was observed to be fully fenced with an unlocked gate and shade will be provided by an umbrella and table combination.

LPA found all facility features to be in compliance and in line with Title 22 Regulations.

An exit interview was conducted and a copy of this report was reviewed with and provided to Administrator Shiloh Cloyd.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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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