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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530003
Report Date: 04/22/2022
Date Signed: 04/22/2022 09:52:39 AM

Document Has Been Signed on 04/22/2022 09:52 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:WINTER PARK HOMEFACILITY NUMBER:
365530003
ADMINISTRATOR:COLLINS, MICHAELFACILITY TYPE:
735
ADDRESS:16350 BURWOOD AVETELEPHONE:
(909) 573-7989
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 0DATE:
04/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Michael CollinsTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Amy Goldenberg conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation.
Structure: Facility was a single story house with four (4) resident bedrooms, one staff bedroom, two 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. This is a change in location and all resident bedroom furniture will be moved with the clients. One bedroom set up at time of inspection adequately meets the required elements.
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 112 degrees F.
Kitchen/Laundry: 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. additional seating will arrive during the transfer to this location.
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.
Garage: Laundry area with washer and dryer were located near the garage. Laundry detergents and cleaning solutions were secured behind a locked cabinet door. Garage was organized and free of obstructions. emergency supplies are stored within.
Emergency Phone Numbers, and Exit Plan: Let-Us-No poster and clients rights are posted.
This facility physical plant is prepared for licensure at this time.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2022
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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