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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881541
Report Date: 05/10/2024
Date Signed: 05/10/2024 10:35:56 AM

Document Has Been Signed on 05/10/2024 10:35 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GOODRICH HOMEFACILITY NUMBER:
331881541
ADMINISTRATOR/
DIRECTOR:		OWENS, VIVIENFACILITY TYPE:
735
ADDRESS:26564 GOODRICH DRIVETELEPHONE:
(714) 249-0747
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY: 4CENSUS: 0DATE:
05/10/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Vivien Owens, LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA met with applicant, Vivien Owens. An initial application to operate an Adult Residential Facility (ARF) was received by the Central Applications Bureau (CAB) on 1/9/2024 for a total capacity of four (4) ambulatory clients. Fire Clearance was granted for four (4) ambulatory clients on 2/5/2024. LPA Shaw Ross 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 three 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. LPA tested water temperatures in client bathrooms. LPA verified water temperatures were measured at 108 and 110 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 box and cabinet. There was adequate room for food storage. LPA observed the stove, refrigerator/freezer to be operational and in good working condition.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GOODRICH HOME
FACILITY NUMBER: 331881541
VISIT DATE: 05/10/2024
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LPA observed there to be adequate seating for meals for all clients. Laundry area with a working 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 the hallway cabinets.
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 dining area. Smoke alarms/carbon monoxide detectors were tested and are in working order. Emergency kits and emergency food for use in the event of an emergency were available. Client records will be stored in locked cabinets in the living area. First Aid kit with required components, and locked cabinet 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.

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 to Licensee, Vivien Owens.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC809 (FAS) - (06/04)
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