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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880526
Report Date: 01/15/2025
Date Signed: 01/15/2025 04:00:53 PM

Document Has Been Signed on 01/15/2025 04:00 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:DEMOH ADULT HOME IFACILITY NUMBER:
361880526
ADMINISTRATOR/
DIRECTOR:		PATRICK, MICHAELFACILITY TYPE:
735
ADDRESS:13700 CYPRESS AVETELEPHONE:
(760) 596-4994
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 4DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Crystal Pedraza, House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 1/15/2025 at 01:30 PM, Licensing Program Analyst (LPA) Eldin Serrano conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPA was greeted by House Manager Crystal Pedraza and gained access at the home. LPA explained the purpose of the visit to Administrator.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). The facility is licensed for 4 of which can be ambulatory. LPA Serrano completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA observed four (4) clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 71 degrees Fahrenheit. LPA Serrano inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA Serrano inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 118 degrees Fahrenheit. The facility is equipped with operational smoke detectors and carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book.

Posters such as the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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: DEMOH ADULT HOME I
FACILITY NUMBER: 361880526
VISIT DATE: 01/15/2025
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Yards/Outside: One shaded patio, two (2) side gates with self-latching handle on both side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA Serrano observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed four (4) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPA observed files reviewed were complete. LPA also reviewed three (3) staff and administrator's file for First Aid/CPR certification, emergency intervention certification (CPI), criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result and observed files were complete.

LPA audited four (4) clients’ medications and no issues were observed. LPA audited four (4) clients’ Personal and Incidental (P&I) and no issues observed.

No deficiency was cited during this visit. An exit interview was conducted where this report LIC809 was discussed, and copies were provided to House Manager Crystal Pedraza.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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