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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881226
Report Date: 05/05/2023
Date Signed: 05/05/2023 02:18:08 PM

Document Has Been Signed on 05/05/2023 02:18 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:ONE STEP FORWARD ADULT RESIDENTIAL CARE FACILITYFACILITY NUMBER:
361881226
ADMINISTRATOR:AURORA ARZATEFACILITY TYPE:
735
ADDRESS:19766 US HWY-18TELEPHONE:
(562) 221-4466
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 0DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Tyneka Sheriff-LicenseeTIME COMPLETED:
02:25 PM
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On 05/05/23 at 11:30 AM, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted and granted entrance by Licensee, Tyneka Sheriff. LPA toured the facility inside and outside with Licensee. LPA observed that there are currently no clients admitted to the facility.

The facility has 4 bedrooms (3 of 4 have their private side exit), 2 bathrooms ( 1 of 2 private), a kitchen, dining area, 2 living rooms, family room, attached carport, and backyard with gated swimming pool. The facility is pending vendorization by Inland Regional Center. LPA conducted a general overall inspection, which included, but was not limited to, the following:

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 68 degrees F temperature. LPA inspected clients bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. An adequate supply of linens stored in a cabinet inside the laundry room. LPA inspected clients bathrooms; private bathroom is clean and appliances are operating appropriately; shared bathroom is missing the bottom shower faucet and 3 tiles making it inaccessible to future clients. Technical Violation is issued. LPA tested the water temperature in the kitchen faucet, which tested within regulation at 108.2 degrees F. The facility is equipped with 2 operating fire extinguishers, smoke detectors and carbon monoxide alarms. The facility has a fireplace in one of the living rooms and a dutch oven in the second living room. LPA observed that the dutch oven is unlocked and accessible to future clients in care. Technical Violation is issued. Posters such as; the personal rights, the CCL complaint poster, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for client/staff files, first aid kit and medication. The facility has emergency supplies for future clients. There is one locked and gated swimming with jacuzzi in the backyard.. There are no firearms or ammunition in the facility.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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: ONE STEP FORWARD ADULT RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 361881226
VISIT DATE: 05/05/2023
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Yards/Outside:
One shaded patio furniture for outdoor seating along with one locked shed storing Licensee's personal items. Side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Food Service: Non-perishable and perishable food supply is sufficient for future clients in care. Dishes, cups, and utensils were also stored properly.

Record Review: LPA reviewed the facility's file along with the Administrator's file for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

No deficiencies were cited during this visit. Two Technical Violations were issued. An exit interview was conducted where this report LIC809 and LIC809C was discussed and copies were provided to the Licensee, Tyneka Sheriff.

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

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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