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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880937
Report Date: 12/04/2024
Date Signed: 12/04/2024 04:58:09 PM

Document Has Been Signed on 12/04/2024 04:58 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:DAWSON HOMES INC. ON NICHOLAS COURTFACILITY NUMBER:
361880937
ADMINISTRATOR/
DIRECTOR:		HAWTHORNE, KENDRAFACILITY TYPE:
735
ADDRESS:1352 NICHOLAS CTTELEPHONE:
(909) 258-3241
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 4CENSUS: 0DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:44 PM
MET WITH:Kendra Hawthorne, LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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Licensing Program Analyst, LaVette Farlow, (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, three bathrooms, kitchen, living room, dining room, den, laundry room, backyard and attached garage. Pathways throughout the facility were clear and unobstructed. Smoke/Fire alarms were tested and found operational. Fire Extinguisher is fully charged; last inspected March 2024. There are no pools or other bodies of water located on facility grounds. Administrator reports there are no firearms or weapons 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. LPA observed the facility did not maintain a operational phone line. A technical violation was issued. 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: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DAWSON HOMES INC. ON NICHOLAS COURT
FACILITY NUMBER: 361880937
VISIT DATE: 12/04/2024
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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. LPA observed the facility did not maintain a seven (7) day supply of non-perishable food. A technical violation was issued.

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. LPA observed the facility did not maintain a Infection Control Plan or an annual review of the LIC 610E Emergency Disaster Plan for Residential Care Facilities. One (1) deficiency and one (1) technical violations issued.

Based on observations, interviews and records; one deficiencies will be cited per Title 22, California Code of Regulations and three (3) technical violation was issued. 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: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/04/2024 04:58 PM - It Cannot Be Edited


Created By: Lavette Farlow On 12/04/2024 at 04:34 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: DAWSON HOMES INC. ON NICHOLAS COURT
FACILITY NUMBER: 361880937

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 in one (1) out of (1) objects which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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Licensee agrees to complate and review the emergency and disaster plan and have it ready for review by POC 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:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
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