336427424-12-5-2023-56-AS-MMAE-CY8QU2-20231205112802

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427424
Report Date: 12/05/2023
Date Signed: 12/05/2023 11:28:12 AM

Document Has Been Signed on 12/05/2023 11:28 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ADEL'S VILLA		FACILITY NUMBER:	336427424
ADMINISTRATOR:	WILLIAMS, ADELAIDE		FACILITY TYPE:	740
ADDRESS:	1513 WESLEY STREET		TELEPHONE:	(909) 278-1720
CITY:	BANNING	STATE: CA	ZIP CODE:	92220
CAPACITY:	6	CENSUS: 4	DATE:	12/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Aminat Molade, House Manager		TIME COMPLETED:	11:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Aminat Molade, House Manager and discussed the purpose of the visit. The facility has a capacity of (6) residents with a current census of (4) and is a certified vendor for Inland Regional Center (IRC). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no outdoor bodies of water. The facility is enclosed with self-latching gates. The facility has sufficient lighting, linen, towels, and personal hygiene items for residents. The facility fireplace is properly screened and carbon monoxide alarms are working properly. Resident’s bathrooms were operating in safe and sanitary conditions. Bathroom hot water temperatures measured 105 and 108 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. The facility has posted in a common area, resident's personal rights, Community Care Licensing complaint poster, Ombudsman poster, disaster evacuation plan, and emergency telephone numbers. Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezers are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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: ADEL'S VILLA	FACILITY NUMBER: 336427424
	VISIT DATE: 12/05/2023

NARRATIVE

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Care & Supervision: Facility has 24-hour, 7 days a week care staff.

Record Review: (3) staff files reviewed were observed to be complete and included criminal record clearances or exemptions. (3) resident files reviewed were observed to be complete. Administrator’s certification expires 2/03/24.

Medical Related Services: All medication is centrally stored and kept in a locked cabinet.

Based on LPA observations and record review, 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 House Manager at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

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