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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880739
Report Date: 12/05/2023
Date Signed: 12/05/2023 01:03:50 PM

Document Has Been Signed on 12/05/2023 01:03 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:GORWAY HOME CARE, INC.FACILITY NUMBER:
361880739
ADMINISTRATOR:DRAYTON-MCCALL, SHERRYFACILITY TYPE:
735
ADDRESS:11337 4TH AVENUETELEPHONE:
(818) 270-6530
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 0DATE:
12/05/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Georgine BerrianTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Paola Guerrero made an announced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Licensee Georgine Berrian and was granted entry to the facility. At the time of the visit there was one (1) staff present, currently the facility has a census of zero (0). The facility is a four (4) bedroom, three (3), bathroom home, with a kitchen/dining area, living room, and attached garage. The facility is an Adult Residential Facility (ARF). Licensed capacity is (6) current census (0). LPA was accompanied by Facility Licensee Georgine Berrian, to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: Currently the facility has a census of zero (0) and the facility is pending to be vendorized by Inland Regional Center. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be 105.9 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space where client/staff files will be filed. Medications will be kept inside medication closet inaccessible to clients in care. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of client in care.


Care & Supervision: Facility currently has no working staff.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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: GORWAY HOME CARE, INC.
FACILITY NUMBER: 361880739
VISIT DATE: 12/05/2023
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Record Review: LPA reviewed one (1) staff file for First Aid/CPR certification, criminal record clearance, training, and health screenings.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Licensee Georgine Berrian.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC809 (FAS) - (06/04)
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