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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530055
Report Date: 08/21/2024
Date Signed: 08/21/2024 11:07:13 AM

Document Has Been Signed on 08/21/2024 11:07 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
, CA 92507
FACILITY NAME:QUEENSPARK RESIDENTIAL CAREFACILITY NUMBER:
335530055
ADMINISTRATOR/
DIRECTOR:		CLARK, BEVERLYFACILITY TYPE:
735
ADDRESS:1033 QUEENSPARK RDTELEPHONE:
(909) 559-7454
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY: 4CENSUS: 0DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Beverly Clark-Administrator TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Bernadette Allen made an announced visit to the facility to conduct a closure inspection. LPA met with Beverly Clark- Administrator who granted entry into the facility and informed LPA she has decided to keep the facility open.

The facility is currently licensed as an Adult Residential home that will be vendored by Inland Regional Center. She stated there are additional steps required before she can accept clients. During the inspection LPA observed that there are no clients in the home.



The facility has capacity of four ambulatory clients only age range 18-59.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately.

The hot water temperature tested within regulation at 107.5 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide detectors and fully charge fire extinguishers. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area.

The cleaning supplies and toxins will be locked in the upstairs laundry room. All sharps/knives, medications, staff and clients files will be locked in the kitchen pantry. Overall, the facility appeared to be clean, in good repair, and operating in safe conditions.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients that will be in care.

Care & Supervision: Facility will have sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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
, CA 92507
FACILITY NAME: QUEENSPARK RESIDENTIAL CARE
FACILITY NUMBER: 335530055
VISIT DATE: 08/21/2024
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Record Review:

LPA also reviewed one (1) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

Based on the observations made during today’s visit, no deficiencies were cited.

An exit interview was conducted, and this report was discussed and provided to Beverly Clark- Administrator at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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