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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881525
Report Date: 05/23/2024
Date Signed: 05/23/2024 11:09:59 AM

Document Has Been Signed on 05/23/2024 11:09 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:I STRIVE ARF CORRALFACILITY NUMBER:
331881525
ADMINISTRATOR/
DIRECTOR:		NELSON, SHAWNTAEFACILITY TYPE:
735
ADDRESS:5272 CORRAL WAYTELEPHONE:
(310) 213-7403
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 4CENSUS: 0DATE:
05/23/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Shawntae Nelson, Administrator & John Young, Board MemberTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:05 AM, LPA met with Administrator Shawntae Nelson and Board Member John Young. An initial application for Initial to operate an Adult Residential facility (ARF) was submitted to the Central Applications Bureau (CAB) on 03/14/2024 for a total capacity of four (4) ambulatory, zero (0) non-ambulatory and zero (0) bedridden residents. Fire clearance was granted on 11/15/2023. LPA Delgado observed the following:
Structure:
Facility was a one story house with four (4) resident bedrooms, two (2) resident bathrooms, living 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 dining to control entire house.
Bedrooms:
Each resident bedroom #1, #2, #3 and #4 will accommodate any ambulatory resident. 4 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
Two (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:25 AM, LPA tested the water temperatures in the resident bathrooms.

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SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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: I STRIVE ARF CORRAL
FACILITY NUMBER: 331881525
VISIT DATE: 05/23/2024
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(Continued from Page 1)

LPA verified water temperature was measured at 118 degrees Fahrenheit.

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked cabinet located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the home. Laundry detergents will be stored inside the locked laundry room and cleaning supplies were observed inside a locked cabinet under the sink away from residents.
Living/Family room:
There was a living/family room with sofa and couch for all clients and TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a closet in the main hallway of the residence. Hygiene Supplies observed in hallway.
Yards/Outside:
Patio table and chairs were observed in the backyard with an umbrella. There was a gate on the West side of the property with a self-latching door. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch, Personal Rights, Visitor Policy, LIC500, LIC610D, Let-Us-Know, Activities schedule were observed posted in the main hallway.
General items:
One (1) fire extinguisher were charged and located in the hallway adjacent to the kitchen. Five (5) smoke alarms and one (1) carbon monoxide detectors were tested. Client records, staff files will be stored in a locked closet in the hallway. First Aid kit with required components and locked area for medication storage was observed.

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SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
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: I STRIVE ARF CORRAL
FACILITY NUMBER: 331881525
VISIT DATE: 05/23/2024
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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 and emergency food was observed. Component III was completed on April 25, 2024 at Riverside Regional office.

Pre-Licensing is complete

An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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