361881290-4-5-2022-56-AS-RLAA-CD7Q4L-20220405115030

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881290
Report Date: 04/05/2022
Date Signed: 04/05/2022 11:50:48 AM

Document Has Been Signed on 04/05/2022 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	GOLD DUST WAY		FACILITY NUMBER:	361881290
ADMINISTRATOR:	WARD, JASPER		FACILITY TYPE:	735
ADDRESS:	12517 GOLD DUST WAY		TELEPHONE:	(323) 395-8594
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY: 4		CENSUS: 0	DATE:	04/05/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Kedra Creer, Administrator		TIME COMPLETED:	11:50 PM

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Licensing Program Analyst (LPA) Rohit Lama conducted an announced visit to the pending facility for a pre-licensing inspection. LPA met with Administrator, Kedra Creer.

Fire clearance was granted by the High Desert Office located in Victorville. Clearance was granted for 4 Ambulatory individuals. There are charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. Emergency disaster plans, personal rights, and the Community Care Licensing poster were posted in a prominent area. The facility was equipped with a complete first aid kit and manual as well as emergency supplies.

LPA toured the facility inside and out. The following was observed, reviewed, and inspected:

The facility has 4 bedrooms, 2 bathrooms, living room, kitchen, dining area, backyard, and attached garage.

The physical plant, in general, was in good repair. The buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. There was a shaded area with seating. There was no obstruction on the side yard exits. The gate remained unlocked.

LPA was informed that no firearms or ammunition will be kept at facility. The Administrator has a current Administrator's Certificate with an expiration date of: 09/29/2023.

LPA inspected resident bedrooms. Resident bedrooms have the required bedding and furniture. All bedrooms included clean mattresses, closet space, nightstands, dressers, and sufficient lighting. LPAs inspected resident bathrooms.

CONTINUED ON LIC 809-C.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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: GOLD DUST WAY	FACILITY NUMBER: 361881290
	VISIT DATE: 04/05/2022

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Continued from LIC 809
The bathrooms were operating in safe and sanitary conditions. LPAs measured the hot water temperature, which measured within regulation at 108 degrees F. LPA also observed additional linen and hygiene items for the residents. LPA toured the kitchen. The facility had a 2-day supply of perishable food items and 7-day supply of non-perishable food items. The food was labeled with expiration dates and stored in a safe and healthful manner. The facility had a menu available for review. Dishes, glasses, and utensils were in good condition.

There was a locked and centralized storage area for medications. Cleaning supplies, toxins, and sharps were kept locked away and inaccessible to residents. Additionally, LPA observed facility to have required single entry point for COVID screening, upon entering facility. LPA observed required COVID signages throughout the facility and soap and disposable towels in bathrooms for washing hands.

The facility had a designated area for resident and staff files, which was locked. The facility had working telephones for residents’ use. There was adequate seating in the common areas. LPAs observed activities for the residents such as books and games.

At this time facility has shown to have met pre-licensing requirements.

The facility was evaluated in accordance with Title 22, Division 6, Chapters 1 to ensure the health and safety of residents in care and meets regulation guidelines at this time.

No corrections are needed.

An exit interview was conducted, and a copy of this report (LIC 809) was reviewed with and provided to Administrator.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

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