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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800461
Report Date: 05/05/2023
Date Signed: 05/05/2023 02:14:18 PM

Document Has Been Signed on 05/05/2023 02:14 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SKIOMAH ROADFACILITY NUMBER:
361800461
ADMINISTRATOR:SHARDE CARR, ERICAFACILITY TYPE:
735
ADDRESS:13159 SKIOMAH ROADTELEPHONE:
(818) 309-7821
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 6CENSUS: 3DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Erica Sharde-Carr, AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Amber Coleman arrived unannounced to the Skiomah Road Adult Residential Facility to conduct the required annual visit to the facility. LPA met with Licensee/Administrator, Erica Carr, and introduced self and stated purpose of the visit. LPA was informed there are currently 3 residents in care, they were at their prospective day programs.

The facility has 3 resident bedrooms, 2 bathrooms, a kitchen, dining area, 2 living rooms, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of facility, staff interviews and review of records.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 105 degrees F. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Posters such as; the personal rights and disaster plans were posted in the living room area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed in secure cabinets and inaccessible to residents in the living room. The facility had emergency and first aid kits in file cabinets in the living room readily available for residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.
Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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: SKIOMAH ROAD
FACILITY NUMBER: 361800461
VISIT DATE: 05/05/2023
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Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. No staff reside at the facility.
Record Review: LPA reviewed 2 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 2 staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. P & I funds were counted at random and matched with the ledger. Medications were audited at random and appeared to be dispensed appropriately by staff members. The facility last conducted a disaster drill in April of 2023 - "All clients were able to exit from facility safety."

No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) were discussed and copies were provided to the administrator.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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