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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800105
Report Date: 08/19/2021
Date Signed: 08/19/2021 02:20:12 PM

Document Has Been Signed on 08/19/2021 02:20 PM - 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
RIVERSIDE, CA 92507
FACILITY NAME:LAVERNE'S ABUNDANCE OF LOVEFACILITY NUMBER:
361800105
ADMINISTRATOR:VANA MARIE JUSTICEFACILITY TYPE:
735
ADDRESS:14905 MESA LINDA AVETELEPHONE:
(760) 241-5251
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 4DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Vana Fowler, LicenseeTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Jesse Gardner arrived and conducted an unannounced required annual visit and met with Licensee Vana Fowler. LPA Gardner conducted a walk through of the facility with Ms. Fowler. The facility is licensed for a capacity of 4 residents.

The facility is a two story home which has 4 bedrooms, 3 bathrooms, 3 living rooms, a kitchen/dining room, and a garage. Bathrooms were clean. Toilets, water faucets and lighting worked properly. Water temperature was between 108 degrees and 118 degrees. Hallways and passageways were clear. 2 day Perishable and 7 day non-perishable food supply was checked and was stocked at time of visit. Smoke detectors were checked and are operational.

LPA Gardner toured the backyard and observed it to be fully fenced, with amble shade for the residents via a patio cover attached to the house. The backyard gate did not have a lock on it, and was able to be used as egress for the residents. The fire extinguisher was observed to be fully charged, and secured to the wall.

The kitchen had cups, plates, bowls, utensils, and pots and pans. Sharp knives are kept in a locked closet with cleaning supplies and resident medication.

During the inspection, LPA Gardner discussed infection control practices and procedures with Ms. Fowler. An exit interview was conducted and a copy of this report was reviewed with and provided to Ms. Fowler.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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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