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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409877
Report Date: 01/27/2025
Date Signed: 01/27/2025 11:17:53 AM

Document Has Been Signed on 01/27/2025 11:17 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:CHERRY RANCH RESIDENTIALFACILITY NUMBER:
336409877
ADMINISTRATOR/
DIRECTOR:		DANA WALKERFACILITY TYPE:
735
ADDRESS:11267 CHERRY AVE.TELEPHONE:
(951) 845-2413
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 6CENSUS: 1DATE:
01/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:22 AM
MET WITH:Jennier UlloaTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct an annual inspection. LPA met with Jennifer Ulloa, support staff and she was informed of the purpose of the visit.

The facility is an Adult Residential, 4i, facility. The facility has a license capacity of (6) ambulatory clients. There is currently one (1) client. During today's inspection,there was one (1) staff and the one (1) client was at day program. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: LPA observed indoor and outdoor passageways are kept free of obstructions. The facility has sufficient indoor and outdoor space for client activities. The facility has no bodies of water. The facility is maintained at a comfortable temperature.

Client bedrooms were equipped with furniture and appeared to be in good repair. The client bathroom shower, faucets, and toilet were operating properly. Bathroom hot water temperature was tested at 117 degrees F. The facility has sufficient activity supplies for clients and client activities include community outings and day program participation. The facility has sufficient linen, personal hygiene products, and furniture for clients in care. The facility has operating telephone service, fire/carbon monoxide alarms, and laundry equipment. Cleaning supplies, and sharps were kept locked and inaccessible to clients in care.

Food Service: The facility has sufficient non-perishable and perishable food for number of client in care. The refrigerator and freezer where operating in a healthful manner. The facility has sufficient cups, plates, and utensils for client use.

Care & Supervision: Facility has care staff coverage 24 hours a day, 7 days a week.

Record Review: The facility's last earthquake drill was conducted on 1/15/2025. The Administrator's certification expires on 12/05/2025.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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: CHERRY RANCH RESIDENTIAL
FACILITY NUMBER: 336409877
VISIT DATE: 01/27/2025
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Record Review: LPA reviewed one( 1) Client file for admission agreements, updated physician reports, and needs and services plans. Medications were audited at random and appeared to be dispensed appropriately by staff members. C1 P&I was also audited and matched the ledger.

LPA observed record that C1s IRC case manager Alejandra Vazquez was at the facility on 1/23/2025 to update C1s IPP which has not provided as of 1/27/2025. The licensee was called and she stated that a call will be made to confirm when the required IPP will be received for their records.

LPA also reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings.

Based on the observations made during today’s visit, no deficiencies were cited.

An exit interview was conducted, and this report was discussed and provided to Jennifer Ulloa Support Staff at the conclusion of the visit with appeal rights.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2