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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530225
Report Date: 10/30/2024
Date Signed: 10/30/2024 11:38:13 AM

Document Has Been Signed on 10/30/2024 11:38 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:EWELL FAMILY HOMEFACILITY NUMBER:
335530225
ADMINISTRATOR/
DIRECTOR:		EWELL, MARCFACILITY TYPE:
735
ADDRESS:34888 OLD VINE CTTELEPHONE:
(404) 786-6793
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 4CENSUS: 0DATE:
10/30/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Applicant/Administrator Marc EwellTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On 10/30/2024 at 08:30 AM, Licensing Program Analyst (LPA) Melody Brown conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPA Brown met with Administrator/Applicant Marc Ewell. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 02/28/2024 for a total capacity of four (4) Ambulatory clients. Fire clearance was granted on 04/18/2024. LPA Brown observed the following:

Structure:
Facility is a two (2) story house with four (4) client bedrooms, one (1) staff room and three (3) bathrooms, living room, dining area, laundry room and kitchen. There's an attached two (2) car garage in the left side of the house.

Heating/Cooling System:
Central heating and air conditioning system installed with two (2) central panel located in the main floo and upstairs hallway to control each level of the house.

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

Bathrooms:
The three (3) client/staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. LPA Brown tested the water temperatures in the clients' bathrooms. LPA observed non-slip bath mats in client's shared bathroom. LPA Brown verified water temperature was measured at 106.1 degrees Fahrenheit.

***CONTINUED ON LIC 809-C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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 3
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: EWELL FAMILY HOME
FACILITY NUMBER: 335530225
VISIT DATE: 10/30/2024
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***CONTINUED FROM LIC 809***
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments
were secured in a locked cabinet located in the office room adjacent to the kitchen. There's adequate room for food storage. LPA Brown observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There's adequate seating for meals for all clients. Laundry room with washer and dryer was in the laundry area. Laundry detergents and cleaning supplies were observed in a locked cabinets. 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 upstairs 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 of the home and in the upstairs hallway.

General items:
Two (2) fire extinguishers were charged. There are nine (9) 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 office room. First Aid kit with required components, and locked area for medication storage was observed. LPA Brown also observed First Aid Manual/Book at the facility. LPA Brown observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 951-599-4933.
***CONTINUED ON LIC 809-C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: EWELL FAMILY HOME
FACILITY NUMBER: 335530225
VISIT DATE: 10/30/2024
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***CONTINUED FROM LIC 809***
There is enough Emergency water supply and the required 72-hour emergency food supply for clients and staffs and emergency supplies/kits available at the facility. Component III was completed on this day as well.
Additionally, LPA Brown observed facility having Visitor Sign In/Sign Out Sheet and Client Sign In/Sign Out Sheet, upon entering facility.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of clients in care. Facility appears to be ready for licensure.

An exit interview was conducted, and a copy of this report, LIC809, LIC809C were discussed and provided to Applicant/Administrator Marc Ewell.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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