361880937-12-28-2023-56-AS-ACON-CYXNVZ-20231228094847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880937
Report Date: 12/28/2023
Date Signed: 12/28/2023 09:48:54 AM

Document Has Been Signed on 12/28/2023 09:48 AM - 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:	DAWSON HOMES INC. ON NICHOLAS COURT		FACILITY NUMBER:	361880937
ADMINISTRATOR:	HAWTHORNE, KENDRA		FACILITY TYPE:	735
ADDRESS:	1352 NICHOLAS CT		TELEPHONE:	(909) 258-3241
CITY:	RIALTO	STATE: CA	ZIP CODE:	92377
CAPACITY: 4		CENSUS: 0	DATE:	12/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Kendra Hawthorne, Administrator		TIME COMPLETED:	10:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Dawson Homes Inc. on Nicholas Court Adult Residential Facility, (ARF) to conduct the Annual Inspection. LPA was greeted by Administrator Kendra Hawthorne. LPA introduced self and stated purpose of the visit and was invited inside facility. Administrator reported the facility has no residents at this time; pending a partnership with the Inland Regional Center. LPA was accompanied by Administrator of a walk through of the facility and observed the following: Buildings and Grounds: The facility is a residential home; which includes four bedrooms, two bathrooms, kitchen, living room, dining room, den, laundry room, backyard and attached garage. Infection control station is set up at the entrance of the facility; which included a sign in sheet, personal protective equipment and hand hygiene supplies. Pathways throughout the facility were clear and unobstructed. Smoke/Fire alarms were tested and found operational. Fire Extinguisher is fully charged; last inspected March 2023. There are no pools or other bodies of water located on facility grounds. Administrator reports there are no firearms or weaponry stored at the facility. Rooms for residents all included required furniture such as a bed with appropriate linens, seating, sufficient lighting, adequate storage and privacy. All of which are all in good condition. Bathrooms were both equipped with handrails and non-slip grip material in the bathing areas. Cabinets used for resident's personal hygiene materials. Each bathroom also included adequate hand hygiene and paper supplies. The dining and living room areas were equipped with adequate seating for residents, staff and visitors. The living room includes a space which will be used as a staff office. The office included a desk with securable cabinetry for staff and resident files. Adequate lighting was observed throughout the facility with various light fixtures and night-lights. Linens, towels and extra blankets were observed in a hallway cabinet accessible to those who may need them. The water temperature in the kitchen was tested and measured within regulatory Please LIC9099-C

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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: DAWSON HOMES INC. ON NICHOLAS COURT	FACILITY NUMBER: 361880937
	VISIT DATE: 12/28/2023

NARRATIVE

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limits. The backyard included space for leisure activities, shaded seating and a clutter free exit pathway for emergencies. Activity materials such as books, board games and puzzles were placed in accessible areas. The laundry room is the entry way to the secure garage. It included an operable washer and dryer. In the garage were secure cabinets for the facility's cleaning tools, sharp objects and supplies. The adjacent also secure cabinet will be the designated area for resident medications. The garage also contained the facility's supply of emergency/disaster food, water and linens for both staff and residents. The facility kitchen included an adequate supply of properly stored dishware, utensils, pots and pans. Appliances were observed functional and in good condition.

Administrative./Posters: The following forms were observed to be posted at the facility: Emergency Disaster Plan (LIC 610D), Personal Rights, Facility Sketch (LIC 999), Labor Laws, Ombudsman, Licensing Complaint and Infection Control.

Based on observations, interviews and records; no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Kendra Hawthorne signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

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