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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530079
Report Date: 05/23/2023
Date Signed: 05/23/2023 10:56:45 AM

Document Has Been Signed on 05/23/2023 10:56 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:BELLEVUE ADULT CARE HOME #1FACILITY NUMBER:
335530079
ADMINISTRATOR:COUNTS, KENEFACILITY TYPE:
735
ADDRESS:11972 GADWALL DRIVETELEPHONE:
(951) 547-9176
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
91752
CAPACITY: 4CENSUS: 0DATE:
05/23/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Zipporah KamothoTIME COMPLETED:
11:10 PM
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Licensing Program Analysts (LPAs) Magda Malcore and Bernadette Allen conducted an announced Pre-Licensing visit to the facility. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Unit (CAU). Fire Clearance was granted on 02/08/23 for a total capacity of four (4) ambulatory. LPAs observed the following:

Physical Plant (Indoor/Outdoor): Indoor and outdoor passageways and inclines are free of obstructions. No bodies of water were observed. Adequate outdoor area is covered and patio furniture is in good repair. Facility has sufficient lighting and operating at a comfortable temperature of 74 degrees F. An adequate amount of seating and furnishing in good repair were observed in the common areas; There is enough space for client activities. Facility telephone service, smoke alarms, carbon monoxide detectors are working properly. Facility fireplace is screened. The designated laundry equipment is in good repair and supplies are kept in a locked cabinet.

Bedrooms: Client bedrooms are equipped with a clean mattress, chair, nightstand, sufficient linen and lighting. No client bedrooms is a passageway to another room.

Bathrooms: Client bathrooms are clean and equipped with operating toilets, washbasins, showers. Hot water temperature measured at 111 degrees F.

Supplies: The facility has sufficient supply of clean linens, towels and hygiene products, emergency flashlights and first-aid.

Food Service: LPAs observed the kitchen and food preparation areas are clean with an adequate number of cups, dishes, and utensils. Food storage cabinets are large enough for a seven (7) day supply of non-perishable foods. Refrigerators and freezers are clean and operating in good condition; there is enough storage for at least two (2) days of perishable foods. Sharps, cleaning supplies, and other toxins are kept secured in a locked cabinet.

Medications: A designated client medication cabinet was observed locked and secure.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 5
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: BELLEVUE ADULT CARE HOME #1
FACILITY NUMBER: 335530079
VISIT DATE: 05/23/2023
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Records: A designated client and staff file cabinet was observed locked and secure.

Administration: Emergency exiting plan and telephone numbers, personal rights and licensing complaint information are posted in a common area.

Overall, the facility is clean and in good operating condition. COMP III orientation was provided to Zipporah Kamotho. Pre-licensing inspection is complete, and this facility has no deficiencies.

An exit interview was conducted, and a copy of this report was provided to Zipporah Kamotho at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC809 (FAS) - (06/04)
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