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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530206
Report Date: 10/04/2024
Date Signed: 10/04/2024 11:40:53 AM

Document Has Been Signed on 10/04/2024 11:40 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GOSHEN RESIDENTIAL FACILITYFACILITY NUMBER:
335530206
ADMINISTRATOR/
DIRECTOR:		AYENI, ADEGOKEFACILITY TYPE:
735
ADDRESS:29775 TANOAK CTTELEPHONE:
(601) 316-4353
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 4CENSUS: 0DATE:
10/04/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Tolulope Adedayo, ApplicantTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On 10/04/2024 at 9:15 AM, Licensing Program Analysts (LPA) Melody Brown and Eldin Serrano conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPAs met with Applicant Tolulope Adedayo and Adegoke Ayeni. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 07/08/2024 for a total capacity of four (4) Ambulatory. Fire clearance was granted on 02/14/2024. LPAs Brown and Serrano observed the following:

Structure:
Facility was a one (1) story house with four (4) client bedrooms, two (2) bathrooms, living room, dining area and kitchen. There was an attached two (2) car garage in the left side of the house.

Heating/Cooling System:
Central heating and air conditioning system installed with one (1) central panel located in the hallway to
control entire house. LPAs observed the house temperature of 75 degrees Fahrenheit.

Bedrooms:
Each client bedrooms accommodate any ambulatory client. All client bedrooms were adequately furnished
with bed, chair, closet, dresser, appropriate linens, adequate lighting, a lamp and an operable smoke/carbon monoxide alarm.

Bathrooms:
The two (2) bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. LPAs Brown and Serrano tested the water temperatures in the clients' bathrooms. ***CONTINUED ON LIC 809-C***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GOSHEN RESIDENTIAL FACILITY
FACILITY NUMBER: 335530206
VISIT DATE: 10/04/2024
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***CONTINUED FROM LIC 809***
LPAs Brown and Serrano verified water temperature was measured at 114 degrees Fahrenheit.

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments
were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPAs Brown and Serrano observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There’s an adequate seating for meals for all clients. Laundry room with washer and dryer. Laundry detergents and cleaning supplies were observed in a locked cabinet. Garage door is locked away from clients.

Living/Family room:
There’s a living/family room with adequate seating for all clients and a working TV.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the hallway of the residence.

Yards/Outside:
Patio furniture for outdoor seating observed. Self-latching handle gate on left side of the house that leads
into the backyard. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed posted near the main entrance. There was Let-Us-No poster observed. Personal rights, house rules and visitor policy were observed posted in a common area.

General items:
One (1) fire extinguisher was charged and located in the kitchen. Five (5) combined smoke detectors and carbon monoxide detectors were tested and were observed to be in working order. Client records and staff records will be stored in a locked cabinet in the hallway. First Aid kit with required components and first aid book, and locked area for medication storage was observed. LPAs Brown and Serrano observed a facility phone and was operational as ***CONTINUED ON LIC 809-C***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GOSHEN RESIDENTIAL FACILITY
FACILITY NUMBER: 335530206
VISIT DATE: 10/04/2024
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***CONTINUED FROM LIC 809***
evidenced of LPAs dialing the number. The phone number designated for the facility is 951-926-0311. LPAs observed that the facility has a transportation to take clients.

There is enough Emergency water supply and the required 72-hour emergency food supply for clients and staffs available at the facility. Component III was completed on this day as well.

Additionally, LPAs Brown and Serrano observed facility having Visitor Sign In/Sign Out Sheet and Client Sign In/Sign Out Sheet, upon entering facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC809 (FAS) - (06/04)
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