<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530003
Report Date: 05/09/2023
Date Signed: 05/09/2023 04:39:31 PM

Document Has Been Signed on 05/09/2023 04:39 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:WINTER PARK HOMEFACILITY NUMBER:
365530003
ADMINISTRATOR:COLLINS, MICHAELFACILITY TYPE:
735
ADDRESS:16350 BURWOOD AVETELEPHONE:
(909) 573-7989
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 4DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Jose Vallejo-CaregiverTIME COMPLETED:
04:45 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 05/09/23 at 02:32 PM, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted by Caregiver, Jose Vallejo. LPA observed that there is currently 1 resident, 1 additional caregiver present in the home and 3 residents in day program. LPA toured the facility inside and outside with caregiver, Jose Vallejo.

The facility has 5 bedrooms, 2 bathrooms, a kitchen, dining area, living room, entry room, attached garage, and backyard. LPA conducted a general overall inspection, which included, but was not limited to, the following:
Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 72 degrees F temperature. LPA inspected residents bedrooms; they are equipped with required furniture per regulations. An adequate supply of linens stored in the hallway closet. LPA inspected residents bathroom; bathroom was clean and appliances were operating appropriately. LPA tested the water temperature in the kitchen faucet which tested at 97.8 degrees F and in bathroom sink faucet which tested 97.1 degrees F. Technical violation issued for water temperature measuring below regulations. The facility is equipped with operating fire extinguisher, 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. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for residents/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.
Yards/Outside:
One shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions. There are fruit trees, fruits, vegetables and herbs planted in the back yard.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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 3
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: WINTER PARK HOME
FACILITY NUMBER: 365530003
VISIT DATE: 05/09/2023
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
26
27
28
29
30
31
32
Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry fully stocked and up to date. Facility has a variety of food available. Menu plan is posted on the kitchen's refrigerator. Dishes, cups, and utensils were stored properly. Emergency food and water were observed inside the garage.

Record Review: LPA reviewed the residents files along with the staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

No deficiencies were cited during this visit. One technical violation was issued. An exit interview was conducted where this report LIC809 and LIC809C was discussed and copies were provided to Licensee, Michael Collins who later arrived at the facility.

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

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3