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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881314
Report Date: 04/27/2022
Date Signed: 04/27/2022 11:17:56 AM

Document Has Been Signed on 04/27/2022 11:17 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:GILGAL ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
361881314
ADMINISTRATOR:ALABI, MATTHEWFACILITY TYPE:
735
ADDRESS:13764 MIMI RDTELEPHONE:
(909) 246-7183
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 0DATE:
04/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Mathew Alabi Administrator & Doris LeramaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate an Adult Residential Facility was submitted to the Central Applications Unit (CAU) on 2/14/2022 for a total capacity of 4 ambulatory residents. Fire Clearance was granted 02/24/2022 LPA, Allen observed the following:

Structure: Facility was a single-story house with four (4) resident bedrooms, three (3) bathrooms, living room, dining area, and kitchen area.

Heating/Cooling System: Central heating and air conditioning systems.

Bedrooms: Each resident bedroom will accommodate ambulatory only clients. All bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by applicant and thermometer read by LPA at 105.2.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked pantry. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.

Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.

Linens and Hygiene Supplies: An adequate supply of linens was available.

Yards/Outside: There is a covered patio area for staff and client use. There were no bodies of water observed anywhere on the property.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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: GILGAL ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 361881314
VISIT DATE: 04/27/2022
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Garage: Garage was organized and free of obstructions. There is a small office space in the garage where confidential personnel and clients records will be stored.

Laundry Area: The laundry area is in hallway exit to the garage. There is a washer and dryer. Laundry detergents and cleaning solutions were securely locked in a cabinet.

Emergency phone numbers and Exit Plan: were posted at entry.

General items: The facility has working carbon and operational detectors. These were tested and operational.

LPA reviewed COMPONENT III with the applicant during this Pre-Licensing Inspection This facility physical plant is prepared for licensure at this time.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
LIC809 (FAS) - (06/04)
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