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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881306
Report Date: 07/11/2022
Date Signed: 07/11/2022 12:54:35 PM

Document Has Been Signed on 07/11/2022 12:54 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:LUCKY J'S CARE HOME, INC.FACILITY NUMBER:
361881306
ADMINISTRATOR:RAVELO, CIELITA F.FACILITY TYPE:
735
ADDRESS:13192 ROLLING HILLS DRTELEPHONE:
(909) 569-2401
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 0DATE:
07/11/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Cielita Ravelo, Administrator
Jerry and Violeta Hermogino, Licensee		TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an announced visit to the facility in order to conduct a pre-licensing inspection for an initial application. LPA identified herself to Administrator, Cielita Ravelo and Licensee’s, Jerry and Violeta Hermogino, who were also advised of the purpose of the visit.

The pending application is for an Adult Residential Facility (ARF). The facility has been granted a fire clearance for a total capacity of four (4) ambulatory clients by the Victorville Fire Department on 03/18/2022. LPA conducted a physical plant tour and observed that the facility is not ready for the prelicensing visit. LPA observed the facility does not have the LIC 610 Emergency and Disaster Plan available at the facility for the LPA’s review. LPA observed the water temperature in the kitchen and bathroom # 1 was 122 degrees Fahrenheit. LPA observed that one pane of the double-pane sliding glass door in the master bedroom is broken.

Ravelo stated that they will take care of all the items that need repair, the water temperature adjustment, and ensuring the LIC 610 Emergency and Disaster Plan will be available at the facility for the LPA’s inspection and review. LPA will reschedule the prelicensing visit with the administrator and the licensees when all items are completed.

An exit interview was conducted where this report was discussed, and a copy of this report was provided to the administrator and the licensees.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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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