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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881228
Report Date: 02/25/2022
Date Signed: 02/25/2022 11:04:52 AM


Document Has Been Signed on 02/25/2022 11:04 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
RIVERSIDE, CA 92507



FACILITY NAME:SEYMORE ADULT RESIDENTIAL INCFACILITY NUMBER:
361881228
ADMINISTRATOR:SEYMORE, TONIETTEFACILITY TYPE:
735
ADDRESS:5073 N. WESTERN AVETELEPHONE:
(310) 946-5257
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY:4CENSUS: 0DATE:
02/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Toniette SeymoreTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Jennifer Semin conducted a pre-licensing inspection and Component III with the licensee/administrator, Toniette Seymore. The application is for an Adult Residential Facility for 4 (four) ambulatory clients.

A tour of the pending facility was conducted inside and out. Overall, the pending facility is clean and in new condition. There are no pools, bodies of water, firearms or ammunition. LPA observed the bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, showers and tubs have grab bars and non-skid mats. The hot water temperature was measured in the client’s bathroom at 108 degrees Fahrenheit. LPA observed food storage and preparation areas are clean and sanitary. Refrigerator and freezer temperatures are maintained at appropriate temperatures. LPA observed a seven (7) day supply of nonperishable food and a two (2) day supply of perishable food. All appliances are clean and operating properly. There is a sufficient supply of linens, towels and personal hygiene items. The first aid kit was reviewed; all items are present including a First Aid Manuel. LPA observed an adequate supply of recreation and leisure items and activities. The backyard is completely enclosed with functioning gate to exit to the front yard. Outdoor space is suitable for client use that includes a table with an umbrella and chairs. The fire extinguisher has been recently serviced and completely charged. Smoke alarms and carbon monoxide detectors are present and functional. Medications are centrally stored and secured in a locked cabinet. All hazardous materials such as, cleaning and disinfecting supplies, knives and other sharps are locked and inaccessible to clients. All required forms are posted in a common area.

Pre-Licensing is complete, and this facility has no deficiencies.

An exit interview was conducted where this report was discussed and provided to Ms. Seymore.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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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