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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530059
Report Date: 06/16/2023
Date Signed: 06/16/2023 10:41:30 AM

Document Has Been Signed on 06/16/2023 10:41 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:MCF HOMEFACILITY NUMBER:
335530059
ADMINISTRATOR:APODACA, CHRISTOPHER JOSHUFACILITY TYPE:
735
ADDRESS:35775 RHONE LANETELEPHONE:
(714) 553-2833
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 4CENSUS: 0DATE:
06/16/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH: Christopher "Mr.Josh" ApodacaTIME COMPLETED:
10:45 AM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the MCF Home announced to conduct a Pre-licensing Inspection/Visit. LPA met with Mr. Josh, Administrator/Licensee who granted entry inside the facility. LPA introduced self and stated purpose of the visit. LPA was provided a space to set up and work.

Application: The application is for an Adult Residential Facility (ARF) submitted on Sept. 1st, 2022. The fire clearance has been granted for four (4) ambulatory residents; approved on 12/8/2022.

Buildings and Grounds: The facility is comprised of six bedrooms which four (4) are resident bedrooms, an office, a laundry room, three (3) bathrooms, two (2) common spaces, kitchen, laundry room, dining area, attached garage and backyard. The exterior pathways of the home were observed to be clear with no obstructions. Smoke and Carbon Monoxide detectors were tested and operational. Interior passageways were clear and free of obstructions. No pools or bodies of water observed on premises. Mir. Josh reports, there are no weapons/firearms stored in the facility. Fireplaces gas lines have been cut to ensure safety of residents. Each bedroom included adequate bedding, night stands, a chair, sufficient lighting, storage and intact window screens. The dining and living room areas were observed to be orderly and in good repair. The water temperature was tested in both the kitchen and bathrooms; they measured ranging between 105-115 degrees Fahrenheit, which is within regulatory limits. Outdoor areas had sufficient space available for activities and leisure. The backyard also included adequate shaded seating. Activity materials such as puzzles, books, and games were observed in common areas of the facility. The facility's laundry room was observed to be behind a secure door. Inside the laundry room also included secure cabinets for storage of cleaning solutions and laundry detergent.

Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MCF HOME
FACILITY NUMBER: 335530059
VISIT DATE: 06/16/2023
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Storage and Supplies: Medications are designated to be stored inaccessible to any unauthorized individuals; in the secure staff office inside secure file cabinets. The staff office will also house staff and resident files; as well as resident finances. The First Aid kit was observed to be readily available to residents and staff. Cleaning supplies are stored in the securely attached garage; along with the facility's additional hygiene supplies, disaster kits, food rations, personal protective equipment. Linens, personal hygiene supplies, and equipment are all in good repair and sufficient for approved census. These items are kept in a hallway closet. Bathrooms were observed to have non-slip bath mats available. Each bathroom included adequate paper and hand hygiene supplies. Fire extinguishers were available and fully charged throughout the facility.

Food Service: LPA observed adequate amounts of utensils and dishware are sufficient for the requested capacity. The refrigerator and stove observed operational. Sharps will be stored in a secured drawer in the kitchen.

Forms: LPA observed the following signs posted throughout the facility: Emergency Disaster Plan (LIC 610D), Personal Rights, Facility Sketch (LIC 999), Labor Laws, House Rules, Grievance Policy, Theft and Loss Policy and Emergency Contact Information.

The facility is ready to be licensed. LPA will notify the Centralized Applications Bureau. COMP. III completed, CARE Tool utilized. An exit interview was conducted; where this report was reviewed and discussed then provided to Administrator/Licensee Mr. Josh.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC809 (FAS) - (06/04)
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