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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881226
Report Date: 02/23/2022
Date Signed: 02/23/2022 01:30:53 PM

Document Has Been Signed on 02/23/2022 01:30 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ONE STEP FORWARD ADULT RESIDENTIAL CARE FACILITYFACILITY NUMBER:
361881226
ADMINISTRATOR:GUITERREZ, PHILLIPFACILITY TYPE:
735
ADDRESS:19766 US HWY-18TELEPHONE:
(562) 221-4466
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 0DATE:
02/23/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Tyneka Sheriff & Phillip GutierrezTIME COMPLETED:
01:45 PM
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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 Licensee, Tyneka Sheriff, and Administrator, Phillip Gutierrez, 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 six ambulatory clients by the Apple Valley Fire Protection District on 11/23/2021. The facility has a total of four resident bedrooms, two bathrooms, a kitchen/dining area, a living room, an activity area, an office area, and backyard. 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, sufficient storage space, chairs, and lighting. LPA inspected resident bathrooms; the bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients. LPA inspected the kitchen; knives, cleaning supplies, and toxins were inaccessible to residents and stored away from food supply. Dishes, glasses, and utensils were in good condition and stored in a safe manner. The kitchen countertop, floors, and appliances were free from debris. There was also a meal menu available for review. LPA inspected the common areas; LPA observed a charged fire extinguisher, operating smoke detectors, and carbon monoxide alarms at the time of visit. LPA observed required postings including visitation policies, personal rights, and the facility's emergency/disaster plan. The facility was equipped with a complete first aid kit. There was a locked and centralized storage area for medications and area for client files and staff files. The facility had a working telephone for client use. There was adequate seating in the common areas. LPA inspected the outdoor space; there is a pool on property, which was properly secured by a fence. There was also a shaded area for residents. LPA observed that side gates were unlocked and kept free of obstruction.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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
RIVERSIDE, CA 92507
FACILITY NAME: ONE STEP FORWARD ADULT RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 361881226
VISIT DATE: 02/23/2022
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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 for clients to reside.

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 also completed COMP III with the applicant at the conclusion of the inspection.

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

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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