361880937-10-17-2025-56-AS-LFAW-DMJVS9-20251017164111

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880937
Report Date: 09/09/2025
Date Signed: 10/17/2025 04:41:19 PM

Document Has Been Signed on 10/17/2025 04:41 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 COURT		FACILITY NUMBER:	361880937
ADMINISTRATOR/ DIRECTOR:	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:	09/09/2025
TYPE OF VISIT:	Required - 1 Year	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:33 PM
MET WITH:	Damian Jeffries, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

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 (LPA) LaVette Farlow arrived announced at the Dawson Homes Inc. on Nicholas Court Adult Residential Facility, (ARF) to conduct the Annual Inspection. LPA was greeted by Administrator Damian Jeffries. 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 to conduct 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 September 18, 2025. 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. 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 was tested and measured at 107.1 and 117.7 which is within regulatory. Please LIC9099-C

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 09/09/2025

NARRATIVE

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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 near the entry way that lead to the 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 cabinet adjacent in the garage 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 maintain non-perishable food items for resident in care.

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 review, no deficiencies were cited per Title 22, California Code of Regulations. A copy of this report LIC809 and LIC809C was read/reviewed with Damian Jeffries signature acknowledging understanding and receipt of this report.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025

LIC809 (FAS) - (06/04)

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