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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880994
Report Date: 12/20/2024
Date Signed: 12/20/2024 12:57:21 PM

Document Has Been Signed on 12/20/2024 12:57 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 ZUNIFACILITY NUMBER:
361880994
ADMINISTRATOR/
DIRECTOR:		ADEWALE ADERONMUFACILITY TYPE:
737
ADDRESS:23250 ZUNI ROADTELEPHONE:
(760) 961-0707
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 4CENSUS: 4DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:02 AM
MET WITH:Adewale Aderonmu-AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:16 PM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Adewale Aderonmu and introduced self and stated purpose of the visit. LPA was informed that there are currently 3 clients at home and 1 hospitalized.

The facility has 4 bedrooms, 3 bathrooms, office, kitchen, dining area, living room, medication room, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of facility, review of records, medication and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 108.6 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire sprinklers and charged fire extinguishers. Posters such as; the personal rights, emergency disaster plan and CCL complaint poster were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets and drawers inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were observed in secure cabinets and inaccessible to clients. The facility had emergency kits and emergency water inside the garage. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PEOPLE'S CARE ZUNI
FACILITY NUMBER: 361880994
VISIT DATE: 12/20/2024
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Yards/Outside: One shaded patio, a front gate that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed the facility's liability insurance, surety bond and emergency drills. Medication and P&I were audited and matched with records.

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, and LIC809C were discussed and copies were provided to Administrator, Adewale Aderonmu.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC809 (FAS) - (06/04)
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