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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881228
Report Date: 03/17/2023
Date Signed: 03/17/2023 10:16:11 AM

Document Has Been Signed on 03/17/2023 10:16 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: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:
03/17/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Toniette SeymoreTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) ty AdministraPaola Guerrero made an announced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Facility Administrator Toniette Seymore and was granted entry to the facility. At the time of the visit there was no (0) clients at the facility.

The facility is a four (4) bedroom, three (3) bathroom home, with a kitchen/dining area, living room, and attached garage. The facility is an Adult Residential Facility (ARF) level 4i designated home vendorized by Inland Regional Center. Licensed capacity is (4) current census (0). LPA was accompanied by Facility Administrator Toniette to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting. LPA inspected client bedrooms; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 105.6 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications will be kept inside entrance closet inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
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: SEYMORE ADULT RESIDENTIAL INC
FACILITY NUMBER: 361881228
VISIT DATE: 03/17/2023
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Care & Supervision: All staff members working in the facility will have criminal record clearance through the department.

Record Review: LPA reviewed administrator file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Toniette Seymore.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC809 (FAS) - (06/04)
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