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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881228
Report Date: 03/19/2025
Date Signed: 03/19/2025 11:50:23 AM

Document Has Been Signed on 03/19/2025 11:50 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SEYMORE ADULT RESIDENTIAL INCFACILITY NUMBER:
361881228
ADMINISTRATOR/
DIRECTOR:		SEYMORE, TONIETTEFACILITY TYPE:
735
ADDRESS:5073 N. WESTERN AVETELEPHONE:
(310) 946-5257
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY: 4CENSUS: 3DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Lez Zavier Jones, House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Becky Mann conducted an unannounced required 1-year visit to the facility. LPA met with Lez Zavier Jones, House Manager and discussed the purpose of the visit. The facility is an Adult Residential Facility (ARF). Licensed capacity of 4 with a current census of 3. LPA conducted an overall inspection of the facility, 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 comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: beds, mattresses, night stands, storage space, and sufficient lighting. Bathrooms were clean and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested between 105 and 107 degrees Fahrenheit. 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. All sharps are locked. There was a designated area for client/staff files. Overall, the facility is clean, in good repair, and operating in a safe condition 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.

Care & Supervision: Facility does have sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SEYMORE ADULT RESIDENTIAL INC
FACILITY NUMBER: 361881228
VISIT DATE: 03/19/2025
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Record Review: LPA reviewed (3) client files for admission agreements, updated physician reports, and needs and services plans. Client files are maintained and up to date. LPA reviewed (1) client medications. Medications are labeled and administered as prescribed. Medications are kept locked and inaccessible to clients in care. LPA also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Facility's staff records are up to date.

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, LIC809C was discussed and provided to House Manager Lez Zavier Jones.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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