361881290-4-25-2023-56-AS-BALN-CR8QCX-20230425120351

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881290
Report Date: 04/25/2023
Date Signed: 04/25/2023 12:04:03 PM

Document Has Been Signed on 04/25/2023 12:04 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
, CA 92507

FACILITY NAME:	GOLD DUST WAY		FACILITY NUMBER:	361881290
ADMINISTRATOR:	CREER, KEDRA		FACILITY TYPE:	735
ADDRESS:	12517 GOLD DUST WAY		TELEPHONE:	(323) 395-8594
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY: 4		CENSUS: 3	DATE:	04/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Patricia Woods Staff		TIME COMPLETED:	12:15 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analysts (LPA's) Bernadette Allen and Magda Malcore made an unannounced visit to the facility to conduct an annual inspection at 9:55 AM. At the time of the visit there was no answer at the door so the administrator Kedra Creer was called. Kedra had to call the staff member Patricia to return back to the facility to allow LPA's into the home to conducted the annual inspection. Patricia arrived at 10:25 AM. LPA's met with Patricia Wood and Nancy Hernandez and they were informed of the purpose of the visit.

The facility is an Adult Residential Facility (ARF) with 4 bedrooms, 2 bathrooms in the home, LPA observed kitchen/dining area, living room and a family/dining area. LPA's conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPA's inspected the facility inside and out. Indoor and outdoor passageways were kept free of obstruction. The facility has sufficient furniture and lighting and is maintained at a comfortable temperature.

LPA's inspected the kitchen. Facility has sufficient nonperishable and perishable food for number of residents in care. Facility has a variety of food available for residents, and menus posted. Facility food is stored in a safe and healthful manner. Sharps are stored and kept locked closet near the kitchen, inaccessible to clients in care.

LPA's inspected client bedrooms. The bedrooms are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting.

LPA's inspected the bathrooms. Bathrooms were operating in a safe and sanitary conditions. The hot water temperature tested within regulation at 105.5 degrees F.

LPA's observed the facility is equipped with operating carbon monoxide alarms and fully charged fire extinguishers. Posters such as personal rights and the disaster plan were posted in a common area. LPA's did observe cleaning supplies, toxins items are kept in a locked closet and is inaccessible to clients in care.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: 04/25/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The staff and residents files were reviewed and all files had the required documents at the time of the visit.

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 LIC-809, 809-C was discussed and provided to Patricia Woods at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2