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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880989
Report Date: 05/18/2023
Date Signed: 05/18/2023 02:02:18 PM

Document Has Been Signed on 05/18/2023 02:02 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PEOPLE'S CARE SYCAMOREFACILITY NUMBER:
361880989
ADMINISTRATOR:TRANELL MARTINFACILITY TYPE:
737
ADDRESS:17358 SYCAMORE LANETELEPHONE:
(760) 961-1014
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 4CENSUS: 3DATE:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Jorge Ramos- House LeadTIME COMPLETED:
02:15 PM
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 Licensing Program Analyst (LPA) Victoria Chitgian arrived unannounced to conduct a visit to the facility for a required annual inspection. Facility is an Enhanced Behavioral Support Home- Adult Residential Facility. LPA was greeted and granted entry by the lead staff Jorge Ramos. Facility had one client present during the inspection. LPA spoke with the Administrator over the phone, who was unable to be present for the visit.
LPA conducted a walk-through the facility's interior and exterior. Outdoor and indoor passageways were kept free of obstruction, with no hazards observed. The facility has a charged fire extinguisher, operating fire alarm systems, and a carbon monoxide detector present. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review and included nutritious options. LPA toured the client bedrooms. The client bedrooms had functional lighting and required furniture. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 4/23/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Cleaning supplies were stored in the garage locked away. Centrally stored medications were kept in a safe and locked closet. Sharps were stored in a secured area in the kitchen. LPA toured the bathrooms. Hot water temperature was measured in the bathroom and was found within required limits at 108 degrees Fahrenheit. The outside of the facility had a shaded area with seating for client comfort. The facility does not have bodies of water.
LPA reviewed client files. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. All required postings were visible in a common area including the visitation policy, client rights and the Emergency/Disaster plan. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care. Due to time limitations, LPA was unable to review client medications, personnel files, and the P& I ledger.
No deficiencies were issued during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to the lead staff Jorge Ramos, at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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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