361881306-9-6-2023-56-AS-MECA-CVERUL-20230906132009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881306
Report Date: 09/06/2023
Date Signed: 09/06/2023 01:20:16 PM

Document Has Been Signed on 09/06/2023 01:20 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:	LUCKY J'S CARE HOME, INC.		FACILITY NUMBER:	361881306
ADMINISTRATOR:	RAVELO, CIELITA F.		FACILITY TYPE:	735
ADDRESS:	13192 ROLLING HILLS DR		TELEPHONE:	(909) 569-2401
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92395
CAPACITY:	4	CENSUS: 0	DATE:	09/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:12 PM
MET WITH:	Jerry Hermogino- Licensee		TIME COMPLETED:	01:30 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	On 09/06/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted by Licensee, Jerry Hermogino. LPA toured the facility inside and outside with Licensee. LPA observed that there are currently no clients admitted to the facility. The facility has 4 client bedrooms, 2 client bathrooms,1 staff bedroom with 1 staff bathroom, kitchen, dining area, living room, family room, laundry room, attached garage, and backyard. The facility is a specialized home pending vendorization by Inland Regional Center. LPA conducted 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 79 degrees fahrenheit temperature. LPA inspected clients bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. Linens and blankets will be purchased and stored in a closet in the main hallway of the residence. LPA inspected clients bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the water temperature in the kitchen faucet, which tested within regulation at 116.8 degrees fahrenheit. The facility is equipped with operating fire extinguishers, smoke detectors and carbon monoxide alarms. Posters such as; the personal rights, the CCL complaint poster, and disaster plans were posted in a common area. LPA observed that the Emergency Disaster plan was last reviewed in July 21, 2022. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for client/staff files, first aid kit and medication. There are no pools, bodies of water, firearms or ammunition. Overall, the facility is clean, in good repair, and operating in safe conditions for future clients in care. Yards/Outside: One shaded patio furniture for outdoor seating observed. Side gate with self-latching handle on the left and right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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: LUCKY J'S CARE HOME, INC.	FACILITY NUMBER: 361881306
	VISIT DATE: 09/06/2023

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Food Service: Non-perishable and perishable food supply is sufficient for future clients in care. Dishes, cups, and utensils were also stored properly.

Record Review: LPA reviewed the staff's file for First Aid/CPR certification, criminal record clearance, training's, and health screenings. Facility phone number is active and functioning, 760-596-3128.

One technical violation issued and no deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C and LIC9102TV was discussed and copies were provided to the Licensee, Jerry Hermogino.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

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