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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881267
Report Date: 12/14/2021
Date Signed: 12/15/2021 02:44:09 PM

Document Has Been Signed on 12/15/2021 02:44 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HANSEN RESIDENTIAL CAREFACILITY NUMBER:
361881267
ADMINISTRATOR:CLARKE, ZOIEFACILITY TYPE:
735
ADDRESS:374 S. VAN NESS AVE.TELEPHONE:
(310) 490-9069
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 4; 4CENSUS: 0DATE:
12/14/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Administrator-Zoie ClarkTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Bernadette Allen and Amy Goldenberg conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. This visit was conducted via facetime due to COVID-19 as a precautionary measure. An initial application to operate a Adult Residential Facility was submitted to the Central Applications Unit (CAU) on 8/4/2021 for a total capacity of 4 ambulatory residents. Fire Clearance was granted 11/05/2021 LPA's Bernadette Allen and Amy Goldenberg observed the following:

Structure: Facility was a single story house with four (4) resident bedrooms, two bathrooms, living room, dining area, and kitchen area.

Heating/Cooling System: Central heating and air conditioning systems.

Bedrooms: Each resident bedroom will accommodate ambulatory only clients. All bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by applicant and thermometer read by LPA at 105.6 F.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and drawer.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2021
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
RIVERSIDE, CA 92507
FACILITY NAME: HANSEN RESIDENTIAL CARE
FACILITY NUMBER: 361881267
VISIT DATE: 12/14/2021
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 There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.

Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.

Linens and Hygiene Supplies: An adequate supply of linens was available.

Yards/Outside: The back was completed was a patio with adequate covered area for providing shade. There were no obstructions. There were no bodies of water observed anywhere on the property.

Garage: Laundry area with washer and dryer were located in the garage. Laundry detergents and cleaning solutions were secured behind a locked cabinet door. Garage was organized and free of obstructions. There was a recreational leisure area set up for staff and client use.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, Ombudsman poster and clients rights are posted.

General items: The facility has smoke alarms and carbon monoxide detectors. These were tested and operational. LPA observed a facility phone and it was verified to be operational by LPA.

LPA reviewed COMPONENT III with the applicant during this Pre Licensing Inspection.

This facility physical plant is prepared for licensure at this time. This report was provided at the time of visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
LIC809 (FAS) - (06/04)
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