335530055-7-5-2023-56-AS-MRIO-CTFMV3-20230705095604

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530055
Report Date: 07/05/2023
Date Signed: 07/05/2023 09:56:20 AM

Document Has Been Signed on 07/05/2023 09:56 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	QUEENSPARK RESIDENTIAL CARE		FACILITY NUMBER:	335530055
ADMINISTRATOR:	CLARK, BEVERLY		FACILITY TYPE:	735
ADDRESS:	1033 QUEENSPARK RD		TELEPHONE:	(909) 559-7454
CITY:	CORONA	STATE: CA	ZIP CODE:	92880
CAPACITY: 4		CENSUS: 0	DATE:	07/05/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Beverly Clark		TIME COMPLETED:	10:15 AM

NARRATIVE

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Licensing Program Analysts (LPA) Mary Rico conducted an announced Pre-Licensing visit to the facility. LPA met with Facility Administrator Beverly Clark. The pending application is for an Adult Residential Facility. The facility has been granted a fire clearance for a total capacity of four (4) ambulatory on 12/16/2022. The Administrator accompanied LPA on a tour of the inside and outside of the facility. The home is a four (4) bedroom and three (3) bathroom home with a living room, dining room, kitchen, loft and attached garage. The physical plant, in general, was in good repair. The buildings and grounds are free from hazards. The indoor and outdoor passageways are free of obstruction. There are no pools, bodies of water, firearms, or ammunition. All bedrooms are furnished with a bed, nightstand, dresser, and chair. All bedrooms have adequate lighting for clients use. Bathroom's toilet, shower and tubs are in good repair. LPA measured and observed the water temperatures in the bathrooms to be at 120 degrees F. LPA observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer are maintained at appropriate temperatures. All appliances are clean and operating properly. Dishes, glasses, and utensils were in good condition. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present. The backyard is completely enclosed with functioning gate to exit to front yard. The outdoor space is suitable for client use. LPA observed fully charged fire extinguisher present in the facility. Smoke alarms and carbon monoxide are present and functional. Medications are stored and secured in a locked cabinet inaccessible to clients. The facility had a designated area for staff and client records. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There is adequate seating in the common areas. Facility had a supply of activities for the clients.

Pre-licensing inspection is complete, and no corrections are needed to be made.

An exit interview was conducted, and a copy of this report was provided to Administrator Beverly Clark.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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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