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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881669
Report Date: 01/14/2025
Date Signed: 01/14/2025 02:02:12 PM

Document Has Been Signed on 01/14/2025 02:02 PM - 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:ABC 1 LLCFACILITY NUMBER:
331881669
ADMINISTRATOR/
DIRECTOR:
GASAWAY, AMYFACILITY TYPE:
735
ADDRESS:462 WINDFLOWER LANETELEPHONE:
(951) 363-8204
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 6CENSUS: 0DATE:
01/14/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Esther Prothro - AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Ferrer Sabarias made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA met with applicant, Esther Prothro, who accompanied LPA for the inspection. The applicant has applied for six (6) client’s capacity.

Facility is a two-story building with five (5) bedrooms, three (3) bathrooms, laundry room, living room, office, dining area, kitchen and attached garage. LPA observed clients’ bedrooms with the required bedding and furniture, such as, clean mattresses/linen, night stands, dressers, chairs, lighting, and emergency lighting. Client bathrooms had clean appliances that were operating in safe and sanitary condition and the showers contained non-slip surface. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Water temperature in the kitchen and bathrooms measured within regulation at 115.8 degrees F.

Client and staff files will be locked in the office cabinet. Client medication will be centrally stored and locked in the kitchen cabinet. There are no pools or body of water in the premises. All passageways were free from obstruction. LPA observed two fire extinguishers in the facility with the last service date of 1/13/2025. The smoke detectors and carbon monoxide alarms were operational. Applicant stated that there are no known firearms and ammunition on the facility. LPA observed the required postings of the emergency disaster plan, resident personal rights, complaint procedures, employee rights, visitation rights, facility sketch, and the See Something Say Something poster. Facility contains emergency supplies and first aid kits with the required items. The facility has working telephone for client use.

(Continued on LIC 809 C...)

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Ferrer Sabarias
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ABC 1 LLC
FACILITY NUMBER: 331881669
VISIT DATE: 01/14/2025
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(Continued from LIC 809...)

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA determined the facility meets the operational requirements for licensure. Pre-licensing is complete and this facility has no deficiencies. An exit interview was conducted, and this report was discussed and provided to applicant Esther Prothro.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Ferrer Sabarias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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