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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880910
Report Date: 03/10/2025
Date Signed: 03/10/2025 03:45:48 PM

Document Has Been Signed on 03/10/2025 03:45 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:K & J ADULT RESIDENTIALFACILITY NUMBER:
361880910
ADMINISTRATOR/
DIRECTOR:		HOLMAN, JERRHONDAFACILITY TYPE:
735
ADDRESS:5091 ROOSEVELT STTELEPHONE:
(562) 225-1038
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 4CENSUS: 3DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Samuel Idowu, Direct Suppot ProfessionalTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 3/10/2025 at 12:20 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 Direct Support Professional (DSP) Samuel Idowu and gained access to the home. LPA explained the purpose of the visit to DSP Samuel Idowu.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, carport, 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 three (3) client during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 72 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 have 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: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: K & J ADULT RESIDENTIAL
FACILITY NUMBER: 361880910
VISIT DATE: 03/10/2025
NARRATIVE
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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, and (2) car carport observed. LPA observed that the side gate that leads to the backyard was locked and the DSP unlocked it right away upon noticing. Deficiency will be issued. 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 three (3) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPA observed that client #3 (C3) needed to get an updated/signed physician report (LIC602) to indicate Tuberculosis (TB) test result negative. LPA also reviewed (2) 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. LPA observed that staff #1 (S1)needed an updated/signed health screening (LIC503) to indicate TB test result negative.

LPA audited three (3) clients’ medications and no issues were observed. LPA audited one (1) clients’ Personal and Incidental (P&I) and no issues observed.

Deficiency were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, and Appeal Rights were discussed, and copies were provided to DSP Samuel Idowu.

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

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/10/2025 03:45 PM - It Cannot Be Edited


Created By: Eldin Serrano On 03/10/2025 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: K & J ADULT RESIDENTIAL
FACILITY NUMBER: 361880910

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by locking the side gate of the facility that leads to the backyard and no fire clearance obtained for secured perimeters which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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Licensee stated to train all staff on CCR 80020(a) and submit proof of training signed by the staff and a statement of understanding of CCR 80020(a) to LPA Serrano on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/10/2025 03:45 PM - It Cannot Be Edited


Created By: Eldin Serrano On 03/10/2025 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: K & J ADULT RESIDENTIAL
FACILITY NUMBER: 361880910

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #1 (S1) have the signed/updated health screening report LIC503 to show the Tuberculosis (TB) test result negatvie which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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Licensee to submit a physician appointment date for Staff #1 (S1) to have a completed and signed LIC503 form by the plan of correction (POC) due date.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview record review, the licensee did not comply with the section cited above by not ensuring that Client #3 (C3) have the updated/signed physician report LIC 602 to show tuberculosis (TB) test result negative which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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Licensee to submit a physician appointment date for Client #3 (C3) to have a completed and signed LIC 602 form by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4