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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800222
Report Date: 07/22/2024
Date Signed: 07/22/2024 11:43:46 AM

Document Has Been Signed on 07/22/2024 11:43 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:11772 JUSTINE WAYFACILITY NUMBER:
361800222
ADMINISTRATOR/
DIRECTOR:		SHANELLREYA KNOWLESFACILITY TYPE:
735
ADDRESS:11772 JUSTINE WYTELEPHONE:
(760) 991-6602
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 4DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Shanellreya Knowles - AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required annual inspection of the facility. LPA met with Shanellreya Knowles, Administrator, and discussed the purpose of the visit.

The facility is an Inland Regional Center (IRC) certified vendor with a current census of (4) clients. LPA conducted an inspection of the facility, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. Facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor activity space for clients. The facility’s outdoor activity area is fenced with self-latching gates. The facility was equipped with operating carbon monoxide alarms and telephone service. The sufficient supply of bed linen, towels, emergency supplies and hygiene products for clients in care. Client bedrooms were equipped with beds, bed linen, chairs, storage space and sufficient lighting. Client bathroom equipment was operating in safe and sanitary conditions. The hot water in client bathroom tested at 107 degrees F. The facility has posted in a common area: emergency telephone numbers, Community Care Licensing complaint poster, facility sketch, and client personal rights. Sharps and cleaning supplies were kept locked and inaccessible to clients in care.

Food Service: The facility has sufficient non-perishable and perishable food for number of clients in care. The facility’s freezer temperature was maintained at zero degrees. The facility’s refrigerators were maintained at 44 degrees F. The facility has sufficient cups and plates for client use.

Health Related Services: All client medications are labeled and centrally stored in a locked area and inaccessible to clients in care. The facility has a first aid manual and first aid kit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: 11772 JUSTINE WAY
FACILITY NUMBER: 361800222
VISIT DATE: 07/22/2024
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File Review: Staff records audited had health screenings, application records, criminal record clearances, and first aid/CPR training certifications. Client records audited had admission’s agreements, medical assessments, needs and service plans, and Personal and Incidental logs (P&I). Client and staff registry was centrally stored. The Administrator's certification was current. The last facility fire drill was conducted on 6/3/24.

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 Administrator at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC809 (FAS) - (06/04)
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