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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880881
Report Date: 09/16/2024
Date Signed: 09/16/2024 02:35:25 PM

Document Has Been Signed on 09/16/2024 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CIRCLE OF HEARTS ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
361880881
ADMINISTRATOR/
DIRECTOR:		MOORE, TINAFACILITY TYPE:
735
ADDRESS:13830 BAYBERRY STTELEPHONE:
(760) 998-2031
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 2DATE:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:54 PM
MET WITH:Tina Moore-AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Tina Moore, and introduced self and stated purpose of the visit. LPA was informed that all 2 clients are in day program.

The facility has 4 client bedrooms, 2 bathrooms, office, kitchen, dining area, living room, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of facility, review of records, medication and P&I audit.

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 of 77 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 120 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguishers, and first aid kits. Posters such as; the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets inaccessible to clients. Medications and clients/staff files were observed inside a cabinet in the office made inaccessible to clients. The facility had emergency kits, emergency food and water in the garage. There are no pools, bodies of water, firearms or ammunition. 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 clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
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: CIRCLE OF HEARTS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 361880881
VISIT DATE: 09/16/2024
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Yards/Outside: One shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

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

Record/Medication Review: LPA reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. The facility last conducted a fire drill in August 22, 2024. LPA observed emergency drills not conducted for each shift. Technical violation issued. Medications and P&I were audited at random and appeared to be managed appropriately by staff.

No deficiencies and one technical violation was cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, and LIC9102TV were discussed and copies were provided to the Administrator, Tina Moore.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC809 (FAS) - (06/04)
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