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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881115
Report Date: 08/24/2023
Date Signed: 08/24/2023 10:49:08 AM

Document Has Been Signed on 08/24/2023 10:49 AM - 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:COOLWATER HOUSEFACILITY NUMBER:
361881115
ADMINISTRATOR:WILLIAMS, ADELAIDE OFACILITY TYPE:
735
ADDRESS:13429 COOLWATER STREETTELEPHONE:
(442) 242-7924
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 0DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Adelaide Williams-AdministratorTIME COMPLETED:
10:55 AM
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On 08/24/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Adelaide Williams, and introduced self and stated purpose of the visit.

The facility has 5 bedrooms, 4 bathrooms, kitchen, dining area, living room, loft, laundry room, attached garage, and backyard. The facility is awaiting to be vendorized by Inland Regional Center. LPA completed a walk through of the 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 79 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 106.3 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms first aid kit, and charged fire extinguishers. Posters such as; the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. LPA observed the emergency disaster plan last reviewed on 01/15/21. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to clients. There was a designated storage space for client/staff files and medications in secure filing cabinets. Overall, the facility is clean, in good repair, and operating in safe conditions for future clients in care.

Food Service: LPA observed non-perishable and perishable food supply, dishes, cups, and utensils stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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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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: COOLWATER HOUSE
FACILITY NUMBER: 361881115
VISIT DATE: 08/24/2023
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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.

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 administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

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, Adelaide Williams.

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

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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