361881026-1-28-2021-18-AS-DMUN-BXPQND-20210128111858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881026
Report Date: 01/26/2021
Date Signed: 01/28/2021 11:19:59 AM

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:	HESPERIA SENIOR CARE		FACILITY NUMBER:	361881026
ADMINISTRATOR:	WANG, JIN A		FACILITY TYPE:	740
ADDRESS:	17583 SULTANA STREET		TELEPHONE:	(760) 440-7654
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY:	18	CENSUS: 0	DATE:	01/26/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Jin A Wang, Licensee/Administrator		TIME COMPLETED:	03:00 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 Deborah Mullen met with Jin A. Wang, Licensee/Administrator to conduct a pre-licensing inspection. The inspection was conducted by video due to Covid-19 restrictions. The Component III Orientation was conducted with Ms. Wang after the inspection of the house. The home is a (9) bedroom home with a living room, dining room and kitchen. Each bedroom has a full bathroom with shower. Per the fire clearance, the licensee is approved for 18 non-ambulatory residents. All bedrooms are furnished with 2 beds, 2 night stands, a dresser and 2 chairs. The bedroom closet also has built in shelves which will be designated for the second residents use, in lieu of a second dresser. Bedrooms have adequate lighting for residents’ use. The living room was observed to have a couple of folding chairs but was not fully furnished. The facility currently has a sufficient supply linens of towels for residents. Cleaning supplies are locked and stored in the storage room which is adjacent to the staff room. The laundry room is accessible from the exterior of the building. The laundry room is kept locked. Staff and resident files will be locked in cabinet located in the office area. The medications will be stored in a locked cabinet in the kitchen. A first aid kit was present and observed to be complete. The backyard had a covered patio with tables and chairs. Documents required to be posted in public view were observed to be present, with the exception of the Long Term Care Ombudsman poster. While the facility did have plates, bowls and coffee cups for 8 residents, there were additional place settings as well as cooking supplies needed. Also, the licensee stated they had planned on having meals brought in until they were at full capacity. Licensee was advised that confirmation would be obtained by LPA as to whether or not this was allowed by regulations.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2021

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: HESPERIA SENIOR CARE	FACILITY NUMBER: 361881026
	VISIT DATE: 01/26/2021

NARRATIVE

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The licensee will need to correct the following items prior to the pre-licensing inspection being completed:

Proof of a fully supplied kitchen which includes plates, bowls, cups, and silverware for 18 residents. Also, pots and pans, serving dishes and cooking utensils are required.
Living room fully furnished
Non-perishable foods for residents. Perishable foods can be purchased and verified by LPA once the facility is licensed.
Long Term Care Ombudsman poster posted in common area
Activities supplies (i.e. games, puzzles, cards, crafting supplies etc.)

An exit interview was conducted, and a copy of this report was emailed to Ms. Wang for her review and signature.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2021

LIC809 (FAS) - (06/04)

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