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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880994
Report Date: 08/31/2021
Date Signed: 12/28/2021 12:07:55 PM

Document Has Been Signed on 12/28/2021 12:07 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
RIVERSIDE, CA 92507
FACILITY NAME:PEOPLE'S CARE ZUNIFACILITY NUMBER:
361880994
ADMINISTRATOR:CARSON, STEPHANIEFACILITY TYPE:
737
ADDRESS:23250 ZUNI ROADTELEPHONE:
9093427163
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 4CENSUS: 0DATE:
08/31/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lee Strollo, Director of Quality Assurance and Development, Cristin Nicoletti, Project ManagerTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Amy Goldenberg conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate a Adult Residential Facility was submitted to the Central Applications Unit (CAU) on 06/26/2020. Fire Clearance was granted 10/29/20 for 4 non-ambulatory residents and delayed egress on the front gate leading to the door, with a 30 second delay. LPA met with Lee Strollo, Director of Quality Assurance and Development, Cristin Nicoletti, Project Manager.

LPA Goldenberg observed the following:

Structure: The house had a rolling gate at the end of the driveway with a pedestrian gate for access. The facility has a fence surrounding the perimeter of the property. The gate will be accessible with a door bell alert to the staff for access to the property. Facility was a single story house with four (4) resident bedrooms, three bathrooms, office space, one common area, dining area, and kitchen area.

Heating/Cooling System: Central heating and air conditioning systems.

Bedrooms: All bedrooms were adequately furnished with a bed, chair, large closet, appropriate linen, adequate lighting.

Bathrooms: Bathrooms have a toilet, wash basin, and shower. An adequate supply of towels, toilet paper, and toiletries have been made available for incoming clients. Water temperature measured by applicant and thermometer read by LPA at 107 degrees Fahrenheit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2021
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PEOPLE'S CARE ZUNI
FACILITY NUMBER: 361880994
VISIT DATE: 08/31/2021
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Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans are observed. Cleaning supplies and knives/sharp instruments are secured in a locked cabinet or drawer. There is adequate room for food storage. Refrigerator/freezer are in working condition. There is adequate seating for meals.

Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.

Yards/Outside: The back was completed with adequate covered area for providing shade. The facility has seating available for client use. There were no obstructions to the walkway, entrances or exits. There were no bodies of water observed anywhere on the property.

Garage: Multi- car garage with locked cabinets for storage. Emergency supplies are stored in the garage.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster and clients rights are posted. Each bedroom room has an emergency evacuation route posted.

General items: The fire/smoke/carbon monoxide alarm system was tested and operational. LPA verified that the facility telephone number is operational, water and electricity is turned on. Delayed egress system was demonstrated during this visit and is operational with a fire door.

LPA Natalie Gayoso conducted COMP III presentation via tele-visit with Administrator, Naomie Arroyo on 1/20/2021.

There are no identified potential hazards identified as a result of this visit. This facility physical plant is prepared for licensure at this time.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC809 (FAS) - (06/04)
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