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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412338
Report Date: 06/19/2024
Date Signed: 06/19/2024 10:58:05 AM

Document Has Been Signed on 06/19/2024 10:58 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CHARLINE'S ADULT RESIDENTIAL FACILITY IIFACILITY NUMBER:
336412338
ADMINISTRATOR/
DIRECTOR:		WILLS, CHARLINEFACILITY TYPE:
735
ADDRESS:24956 SPRINGBROOK WAYTELEPHONE:
(951) 246-7339
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 4CENSUS: 4DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Licensee, Charline WillsTIME VISIT/
INSPECTION COMPLETED:
11:00 PM
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On 6/19/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to conduct an annual required inspection. LPA was greeted and granted entry by Licensee, Charline Wills who was informed of the purpose of the visit. The facility has a fire clearance for four (4) ambulatory clients and serves adults ages 18 through 59.

During the visit, there was two (2) clients and one (1) staff present and LPA was informed two (2) clients were at day program. LPA toured the facility with Licensee. During the tour, LPA observed the facility is made up of a one (1) story home with two (2) client bedrooms and one (1) client bathroom along with a kitchen, dining room, living room, family room and attached garage. LPA did not observe any bodies of water on the premises. Indoor and outdoor passageways are free of obstruction. LPA observed charged fire extinguishers mounted throughout the facility, serviced on 3/19/2024. Licensee tested one (1) of the smoke alarm/carbon monoxide detectors and LPA observed it to be operational. The facility conducts monthly fire drills and has backpacks filled with emergency supplies available for the clients. Client bedrooms were each furnished with a bed, chair and night stand. Bathrooms have a working toilet, wash basin and non-skid mats in the shower. LPA toured the kitchen and observed the facility had a 2-day supply of perishable foods and 7-day of non-perishable food items. Medications were secured in a kitchen cabinet. LPA also reviewed two (2) client files. Client files reviewed had updated Individual Program Plans and signed admission agreements. Licensee reviewed the physical monies for two (2) clients in front of LPA and LPA cross-referenced the clients' financial record and did not discover any discrepancies.

During today's visit, LPA did not issue any deficiencies. An exit interview was conducted and a copy of this report was reviewed and provided to Licensee.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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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