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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881267
Report Date: 12/15/2023
Date Signed: 12/15/2023 02:59:08 PM

Document Has Been Signed on 12/15/2023 02:59 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
SAN BERNARDINO, 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:
(909) 608-1699
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 4CENSUS: 0DATE:
12/15/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Zoie ClarkeTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Paola 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 Zoie Clarke and was granted entry to the facility. At the time of the visit there was one (1) staff present. Currently facility has not clients in care facility is pending investigation clients will be placed back once cleared. The facility is a four (4) bedroom, two (2), bathroom home, with a kitchen/dining area, living room, and detached garage. The facility is an Adult Residential Facility (ARF) level 4i home vendorized by Inland Regional Center. Licensed capacity is (4) current census (0). LPA was accompanied by Facility Administrator, to conduct a general overall inspection, 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 clients bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be 120 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 clients/staff files. Medications are kept inside kitchen cabinet inaccessible to clients in care; LPA observed an in-ground pool in the backyard, the perimeter of the pool is gated and locked. 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 residents in care.

Care & Supervision: Facility currently has no staff members working at the facility. Previous staff members have criminal record clearance through the department.



Record Review: LPA reviewed four (4) client files of all client that were removed. LPA reviewed admission agreements, updated physician reports, and needs and services plans. LPA also reviewed one (1) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. P&I funds were counted for and matched with the ledger.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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: HANSEN RESIDENTIAL CARE
FACILITY NUMBER: 361881267
VISIT DATE: 12/15/2023
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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 Zoie Clarke.

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

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC809 (FAS) - (06/04)
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