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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881186
Report Date: 03/29/2022
Date Signed: 03/29/2022 11:01:46 AM

Document Has Been Signed on 03/29/2022 11:01 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:SOFIA CARE CENTERFACILITY NUMBER:
361881186
ADMINISTRATOR:LAYGO, ADRIANFACILITY TYPE:
735
ADDRESS:19173 YANAN ROADTELEPHONE:
(909) 623-4964
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 0DATE:
03/29/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Adrian LaygoTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Stephanie Williams made an announced visit to the facility in order to conduct a pre-licensing inspection for an initial application. LPA Williams identified herself to Administrator, Adrian Laygo, who was also advised of the purpose of the visit.

The pending application is for a Adult Residential Facility. The facility has been granted a fire clearance for a total capacity of four ambulatory clients by the Apple Valley Fire Protection District on 2/11/2022. The facility has a total of four client bedrooms, one staff room/office, three bathrooms, a kitchen/dining area, a living room, a family room, laundry room, backyard, and attached garage. LPA toured the interior and exterior areas of the facility. The following was inspected:

LPA inspected client bedrooms; the bedrooms have the required bedding and furniture, such as, clean mattresses/linen, night stands, dressers, chairs, and lighting. LPA inspected client bathrooms; the bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients. LPA inspected the kitchen, which contained utensils and dishware in good condition for the clients. LPA also observed that kitchen appliances and kitchen countertop were free of debris and in good repair. There was also a meal menu available for review. LPA inspected the common areas; in which LPA observed that there was a locked area for knives/sharps, cleaning supplies/toxins, and medications. LPA observed a charged fire extinguisher, operating smoke detectors, and carbon monoxide alarms at the time of visit. LPA observed required postings including the visitation polices, emergency/disaster plans, and personal rights. The facility was equipped with a complete first aid kit and manual. There was a locked and centralized storage area for client files and staff files. The facility had a working telephone for client use. There was adequate seating and activity space in the common areas. LPA observed that all passageways were free from obstruction. Overall, LPA Williams observed no apparent health and safety risks at the time of visit. LPA has determined that the facility has met operational requirements.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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
, CA 92507
FACILITY NAME: SOFIA CARE CENTER
FACILITY NUMBER: 361881186
VISIT DATE: 03/29/2022
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The pre-licensing inspection is complete and this facility has no deficiencies. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations. LPA Williams determined to waive COMP III as the Administrator/Licensee has several other licensed facilities in good standing.

An exit interview was conducted where this report was discussed and a copy was provided to Laygo at the conclusion of the inspection.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC809 (FAS) - (06/04)
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