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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530081
Report Date: 05/03/2024
Date Signed: 08/27/2024 01:07:11 PM

Document Has Been Signed on 08/27/2024 01:07 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:GUS RESIDENTIAL HOME INC.FACILITY NUMBER:
335530081
ADMINISTRATOR/
DIRECTOR:		JOAN M. CHARLESFACILITY TYPE:
735
ADDRESS:11466 LYLE LNTELEPHONE:
(305) 297-1328
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 4CENSUS: 0DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Esele OseborTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required 1-year visit to the facility. LPA met with Esele Osebor, Facility Representative, and discussed the purpose of the visit.

The facility is a two story, Adult Residential Facility (ARF). The facility currently has no staff and no clients in care. The facility is pending Inland Regional Center (IRC) certification. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Operation/Physical Plant: The facility has a fire clearance for four (4 ) ambulatory clients. The facility is maintained at a comfortable temperature. The facility’s Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility’s has sufficient indoor and outdoor space for client activities. The facility’s outdoor activity area is fenced with a self-latching gate. The facility is equipped laundry equipment and carbon monoxide alarms. The sufficient supply of bed linen, towels, and personal protective equipment (PPE). The facility has covered waste bins and covered fireplace. Four (4) client bedrooms inspected were equipped with beds, bed linen, dressers and sufficient lighting. Client bathroom toilets, hand washing and showers are in safe and sanitary operating condition. The hot water in client bathrooms tested at 108 degrees F. LPA observed posted in a common area Community Care Licensing Complaint poster, emergency disaster plan with emergency telephone numbers, Administrator certification, and client personal rights.

Food Service: The kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food. The facility’s refrigerator and freezer are maintained in a healthful manner.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GUS RESIDENTIAL HOME INC.
FACILITY NUMBER: 335530081
VISIT DATE: 05/03/2024
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Health Related Services: Currently there a no clients in care. LPA observed a locked cabinet were medications will be centrally stored.

Personnel/Client Records: The Administrator's certification is current. The facility currently has no staff or clients. LPA observed an office area and a locked cabinet were staff and clients records will be stored.

Based on LPA observations, no deficiencies were cited during today’s visit. An exit interview was conducted, where this report was discussed and a copy was provided to the facility representative at the conclusion of the visit.

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

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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