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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880977
Report Date: 11/16/2023
Date Signed: 11/16/2023 03:34:46 PM

Document Has Been Signed on 11/16/2023 03:34 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:LEMON GRASS RESIDENTIAL CAREFACILITY NUMBER:
361880977
ADMINISTRATOR:HAIRE, JANECIAFACILITY TYPE:
735
ADDRESS:10832 LEMON GRASS AVE.TELEPHONE:
(909) 600-9790
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 4CENSUS: 0DATE:
11/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Phalos & Janecia HaireTIME COMPLETED:
03:35 PM
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On this day at 2:05 PM, Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility to conduct a required annual inspection. LPA met with licensees Phalos and Janecia Haire and were informed of the purpose of today's visit. Licensees and LPA toured the interior and exterior of the facility.

The facility is currently licensed as an Adult Residential Facility, pending vendorization by the Inland Regional Center. The facility has capacity four ambulatory clients.

LPA Bueno and Licensees toured the interior and exterior of the facility. The facility has no bodies of water. The facility has shaded patio area. The facility has a working telephone for use. The facility fire extinguisher was last inspected on 11/1/23. Licensees tested carbon monoxide and interconnected smoke detectors and LPA and Licensees found all units to be in working order. A locked centralized cabinet will be used for medications and client files while facility and staff records will be kept in a secured area. Sharps, toxins, and cleaning agents are kept locked in cabinets.

LPA Bueno and Licensees Haire observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, a chair, sufficient storage space, and lighting. The facility had a supply of additional linens and towels. LPA and Licensees observed bathrooms were kept in sanitary conditions and provisions for hygiene items are available. LPA inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. LPA observed adequate seating and activities in the common areas.

LPAs observed all utilities in use however the facility has no clients to date. Technical assistance were issued as reminders for when the facility completes its vendorization. No deficiency cited during the visit. An exit interview was conducted with Licensee Janecia Haire and a copy of this report was provided.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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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