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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881065
Report Date: 03/05/2024
Date Signed: 03/05/2024 02:22:59 PM


Document Has Been Signed on 03/05/2024 02:22 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:YORKSHIRE GARDEN CARE #1FACILITY NUMBER:
361881065
ADMINISTRATOR:LALA, ADETUTU E.FACILITY TYPE:
740
ADDRESS:12667 YORKSHIRE DRIVETELEPHONE:
(760) 605-4674
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:6CENSUS: 0DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Adetutu, Lala- AdministratorTIME COMPLETED:
02:35 PM
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On 03/05/24, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Adetutu Lala and introduced self and stated purpose of the visit. LPA was informed that there are no residents in care.

The facility has 4 resident bedrooms, 2 resident bathrooms, 1 staff bedroom with bathroom as a detached casita, kitchen, dining area, living room, family room, laundry room, attached garage, and backyard. LPA completed a walk through of facility and review of records.

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 70 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperature tested at 106.2 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman and facility license were posted in a common area. LPA also observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident/staff files and medications. There are no bodies of water, guns or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for future residents in care.

Food Service: Non-perishable and perishable food supply is sufficient. Dishes, cups, and utensils were also stored properly.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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: YORKSHIRE GARDEN CARE #1
FACILITY NUMBER: 361881065
VISIT DATE: 03/05/2024
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Yards/Outside: One shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Record Review: LPA reviewed administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed the emergency disaster plan last reviewed on 10/31/20. Technical violation issued.

No deficiencies and one technical violation was cited during this visit. An exit interview was conducted where this report LIC809, LIC809C and LIC9102TV were discussed and copies were provided to the Administrator, Adetutu Lala.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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