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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881260
Report Date: 06/06/2022
Date Signed: 06/06/2022 11:56:15 AM

Document Has Been Signed on 06/06/2022 11:56 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
, CA 92507
FACILITY NAME:MISSION AT HARTZELLFACILITY NUMBER:
361881260
ADMINISTRATOR:CAMPBELL, CAMILLAFACILITY TYPE:
735
ADDRESS:943 HARTZELL AVETELEPHONE:
(909) 328-9790
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 4CENSUS: 0DATE:
06/06/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Camilla and Fritz CampbellTIME COMPLETED:
12:05 PM
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Licensing Program Analysts (LPAs) Rayshaun Nickolas and Anna Bueno made an announced visit to the facility to conduct a pre-licensing inspection for an initial application. LPAs Nickolas and Bueno identified themselves to licensee Camilla and Fritz Campbell and advised them of the purpose of the visit.
The facility has been granted a fire clearance on 05/02/2022 by the City of Redlands Fire Department for a total capacity of four non-ambulatory clients.

The facility has a total of four bedrooms, four of which are clients', two bathrooms, two of which are clients', a kitchen and dining area, a living room, two activity areas, an office area, and backyard. LPAs and licensees toured the interior and exterior of the facility. The facility has no bodies of water. There is a shaded seating area for clients. LPAs observed that side gates were unlocked and free of obstruction. The facility had a working telephone for client use. The facility has charged fire extinguishers, smoke alarms, and carbon monoxide detectors. The facility had a complete first aid kit and manual. A locked centralized storage area for medications. The following were observed of the physical plant:

Client Bedrooms: LPAs observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting.
Client Bathrooms: LPAs observed bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients.
Kitchen and Dining Area: LPAs inspected the kitchen and found cleaning supplies and sharps were kept in a safe and secured place. Dishes, glasses, and utensils were in good condition and stored in a safe manner.

LPAs observed Seven (7) days’ supply of nonperishable food items. The facility menu was available for review. The kitchen countertop, floors, and appliances were free from debris.

**************************CONTINUED ON LIC 809C**************************.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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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
, CA 92507
FACILITY NAME: MISSION AT HARTZELL
FACILITY NUMBER: 361881260
VISIT DATE: 06/06/2022
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Common (living/activity) areas: LPA observed night lights were maintained in the hallways. There is adequate seating in the common areas. The facility had a supply of activities for the clients.

LPAs observed that the physical plant is clean, in good repair, and appear to be hazard-free during today’s visit. LPAs has determined that the facility is meeting operational requirements for current clients. LPAs completed COMP III with the licensee at the conclusion of the inspection.

The pre-licensing inspection is complete, and this facility has no deficiencies. Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed, and a copy was provided to Camilla and Fritz Campbell at the conclusion of the inspection.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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