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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530079
Report Date: 06/19/2024
Date Signed: 06/19/2024 06:27:11 PM

Document Has Been Signed on 06/19/2024 06:27 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:BELLEVUE ADULT CARE HOME #1FACILITY NUMBER:
335530079
ADMINISTRATOR/
DIRECTOR:		COUNTS, KENEFACILITY TYPE:
735
ADDRESS:11972 GADWALL DRIVETELEPHONE:
(951) 547-9176
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
91752
CAPACITY: 4CENSUS: 0DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:00 PM
MET WITH:Licensee/Administrator Zipporah Kamotho and Licensee/Administrator Edward KamothoTIME VISIT/
INSPECTION COMPLETED:
06:20 PM
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On 06/19/2024 at 05:00 PM, Licensing Program Analyst (LPA) Melody Brown made an announced visit to the facility due to the facility recently licensed on 06/05/2023 and no clients at the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Licensee/Administrator Zipporah Kamotho and and Licensee/Administrator Edward Kamotho and was granted entry to the facility. At the time of the visit, no staff present, and zero (0) client present. The facility is a six (6) bedroom,three (3), bathroom home, with a kitchen/dining area, living room, and attached garage. The facility is an Adult Residential Facility (ARF) home and has not been vendorized by Inland Regional Center (IRC). Licensed capacity is (4), and with current census of zero (0). LPA was accompanied by Licensee/Administrator Zipporah Kamotho to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility currently has no clients in care. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA inspected future client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be at 107 degrees Fahrenheit . The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the Community Care Licensing Division (CCLD) complaint poster, and the Emergency Disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible. There was a designated storage space for client/staff files. LPA Brown observed empty medication cabinet where medication will be potentially stored and inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions.

*** Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: BELLEVUE ADULT CARE HOME #1
FACILITY NUMBER: 335530079
VISIT DATE: 06/19/2024
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Food Service: LPA observed seven (7) days non-perishable and two (2) days perishable food supply. Facility has a variety of food available. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility currently has no clients in care. Administrator(s) at the facility have criminal record clearance through the department.

Record Review: LPA observed Licensee/Administrator Zipporah Kamotho and Licensee/Administrator Edward Kamotho have current Administrator Certificate. Also, LPA Brown reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, and health screenings with Tuberculosis test result. Medications were not audited as the facility currently has no clients.

Based on the observations made during today’s visit, no deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Licensee/Administrator Zipporah Kamotho and Licensee/Administrator Edward Kamotho.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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