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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881314
Report Date: 06/15/2023
Date Signed: 06/15/2023 02:08:45 PM

Document Has Been Signed on 06/15/2023 02:08 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: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:
06/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Doris Lerama-LicenseeTIME COMPLETED:
02:15 PM
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On 06/15/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted by Licensee, Doris Lerama. 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 bedrooms, 3 bathrooms, a 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 72 degrees fahrenheit temperature. LPA inspected clients bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. An adequate supply of linens and blankets 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 bathroom faucet, which tested within regulation at 106.7 degrees fahrenheit. The facility is equipped with operating 3 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 April 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. The facility had emergency kits for future clients. 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 right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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: GILGAL ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 361881314
VISIT DATE: 06/15/2023
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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 Administrator's file for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 and LIC809-C was discussed and copies were provided to the Licensee, Doris Lerama.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
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