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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530065
Report Date: 02/15/2023
Date Signed: 02/15/2023 12:00:07 PM

Document Has Been Signed on 02/15/2023 12:00 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:POPPY'S HOMEFACILITY NUMBER:
335530065
ADMINISTRATOR:GARDUNO, TONYAFACILITY TYPE:
735
ADDRESS:6828 LINDSEY CTTELEPHONE:
(951) 285-5587
CITY:EASTVALESTATE: CAZIP CODE:
91752
CAPACITY: 4CENSUS: 0DATE:
02/15/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Tonya Gardugo, LicenseeTIME COMPLETED:
12:00 PM
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Licensing Program Analyst, Amber Coleman, (LPA), arrived at the Poppy's Home Facility to conduct a Pre-Licensing Visit. Application initially submitted 12/2/22. Fire Inspection occurred on 10/19/22. LPA introduced self and stated purpose and plan of the visit. Licensee, Tonya Gardugo greeted and invited LPA inside facility. There are currently no residents in care. Fire Clearance approved capacity of 4 ambulatory residents. LPA was provided space to work. LPA and Licensee completed a walk through interior and exterior of the facility, discussion of LPA observations and completed Comp. III

Tha facility consists of 2 floors. 1st Floor includes kitchen, dining room, 1 resident bedroom, bathroom and 2 living areas. The second floor includes 4 rooms (3 resident and 1 staff), 2 bathrooms and den space.

Resident Rooms: Each resident room was equipped with appropriate furniture, lighting, bedding and storage space for each resident. Licensee plans to reserved the room for personal space.
Client Bathrooms: The bathroom appliances were operating in safe and sanitary conditions. LPA observed night lights in the bathroom and outside in den area.
Kitchen and Dining Areas: Utensils and dishware were observed to be in good condition and accommodating for the resident capacity. Kitchen appliances and countertype were free of debris and in good repair. Sharp objects to be kept in secure closet adjacent to the kitchen.

Please see LIC809C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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: POPPY'S HOME
FACILITY NUMBER: 335530065
VISIT DATE: 02/15/2023
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Common Sitting Areas: There is adequate seating in the common areas. The facility had a supply of activities for the resident and their visitors.
Laundry Room: The area is secured by a door from the living room. A locked cabinet was observed for detergents, cleaning supplies/toxins, and additional hygiene items for residents.
Backyard: LPA observed an in ground pool on premise. Pool is secured by 5ft black metal gate equipped with a self latch and locking mechanism. There are is a covered areas with seating. All passageways were free from obstruction. LPA a shed on the right side of the backyard. Licensee opened shed where LPA observed shed is used for storage of pool and yard materials. LPA requested Licensee submit an updated facility sketch which was completed during visit.

LPA and Licensee observed a locked closet under the stairs that serves as centralized storage for clients and staff files, medications, sharp objects and personal protective equipment (PPE). 2 charged fire extinguishers and operating smoke detectors and carbon monoxide alarms were observed at the time of visit. Smoke/Carbon Monoxide detector operational. LPA observed required postings including the visitation polices, emergency/disaster plans, and personal rights. The facility was equipped with a complete first aid kit and manual. The facility had a working telephone for resident use. Called and confirmed during visit 951-444-6636. The water temperature was tested and observed to be between 106-116 degrees Fahrenheit.

LPA observed that the physical plant is clean, in good repair, and appear to be hazard-free during today's visit. LPA has determined that the facility is meeting operational requirements for potential residents. LPA completed COMP III with Licensee at the conclusion of the inspection. The pre-licensing inspection is complete and this facility has no deficiencies. Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy was provided to Tonya Gardugo.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
LIC809 (FAS) - (06/04)
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