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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800165
Report Date: 12/04/2024
Date Signed: 12/04/2024 02:35:12 PM

Document Has Been Signed on 12/04/2024 02:35 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AUSTIN SMALL ARIZONA FAMILY HOME IIFACILITY NUMBER:
361800165
ADMINISTRATOR/
DIRECTOR:		AUSTIN, ALEXANDRIAFACILITY TYPE:
735
ADDRESS:17049 LA VESU ROADTELEPHONE:
(909) 823-2624
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 6CENSUS: 1DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Alexandria Austin, AdministrationTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analysts (LPAs) Becky Mann and Sarina Ramirez conducted an unannounced required 1-year visit to the facility. LPAs met with Alexandria Austin Administrator and discussed the purpose of the visit. The facility is an Adult Residential Facility, license capacity of 6 with a current census of 1 client. The facility is a three (3) bedroom, one (1) staff room and two and half (2 ½) bathroom, with a kitchen/dining area, living room, and attached garage. LPAs conducted an overall inspection of the facility, which included, but was not limited to the following:

LPAs inspected the facility inside and out. Indoor and outdoor passageways are kept free of obstruction. Facility has no bodies of water. Facility backyard is fenced with self-latching gate. Facility has sufficient space for client indoor and outdoor activities. The facility has sufficient lighting and is maintained at a comfortable temperature.

LPAs inspected the kitchen. Facility has sufficient non-perishable and perishable food for number of clients in care. Facility food is stored in a safe and healthful manner. Facility has sufficient cups, plates, and utensils for client use. Sharps, disinfectants, and chemicals are kept locked and inaccessible to clients in care.

LPAs inspected client bedrooms. Bedrooms are equipped with beds, mattresses, bed linens, night stands, chairs, storage space, and sufficient lighting.

LPAs inspected client bathrooms. Bathroom equipment is operating in safe and sanitary conditions. Hot water temperatures tested between 106 and 112 degrees Fahrenheit.

The facility is equipped with operating carbon monoxide and smoke alarms. Facility has posted in a common area the facility sketch and personal rights. Facility has sufficient supply of linen, towels, and hygiene products for clients in care.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AUSTIN SMALL ARIZONA FAMILY HOME II
FACILITY NUMBER: 361800165
VISIT DATE: 12/04/2024
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LPAs inspected client medication. Medication are labeled and administered as prescribed. Medication is kept locked and inaccessible to clients in care.

LPAs reviewed client file for admission agreement, physician report and record of client safeguarded resources. Client file are maintained and up to date.

LPAs reviewed staff file for criminal record clearance, first aid certification, training, and health screening. Facility's staff records are up to date.

Technical assistance was issued for Infection Control Plan and Disaster Preparedness.

No deficiencies were cited during today's visit per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, where the licensing reports LIC809, LIC809C, LIC9102 were discussed, and copies were provided to the Administrator at the conclusion of the visit.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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