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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530045
Report Date: 12/08/2022
Date Signed: 12/08/2022 11:58:10 AM

Document Has Been Signed on 12/08/2022 11:58 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JHOLLY SPRING VALLEY LAKE ADULT RESIDENTIAL HOMEFACILITY NUMBER:
365530045
ADMINISTRATOR:JOHNSON, LEE A.FACILITY TYPE:
735
ADDRESS:18520 CATAMARAN LANETELEPHONE:
(442) 255-4666
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: DATE:
12/08/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Lee Johnson, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the J Holly Spring Valley Lake Facility to conduct a pre-licensing visit for initial application. LPA was greeted by Administrator, Lee Johnson (Admin..) and invited inside of facility. LPA introduced self and stated purpose of the visit. LPA was asked to sign in and have temperature taken. LPA observed the COVID station to include PPE, sign in sheets for visitors and appropriate infection control signage. LPA also observed the facility to be free of clutter and in comfortable temperature.

Admin.. and LPA began a walk through of the facility. The facility has been granted a fire clearance on 10/11/2022 by the San Bernadino County Fire Protection District for a total capacity of four ambulatory clients. 0 Bedridden and 0 Non-Ambulatory.

The facility is a 2 story house. It includes a total of 4 bedrooms for each client. 1 bedroom downstairs and 3 upstairs. First floor contains the staff lounge, the kitchen, laundry room, living room and Administrator Office.

Administrator and LPA walked outside of the facility to the backyard. The backyard contains two seated shady areas for residents. The facility has two gates on both sides. LPA observed the gates to be unlocks and in good condition. LPA observed no bodies of water on the premises. Each window around the facility was observed is secure with a proper fitting screen free of insects.

The facility has a number of working landlines accessible to clients. Fire and carbon monoxide alarms were tested and found to be operational. LPA observed the designated closet for medications to be secure.

The following were observed of the physical plant:

Continued on LIC809C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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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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: JHOLLY SPRING VALLEY LAKE ADULT RESIDENTIAL HOME
FACILITY NUMBER: 365530045
VISIT DATE: 12/08/2022
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Client Bedrooms (4): LPA's observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, mattress covers sufficient storage space, chairs, and lighting.

Client Bathrooms (2.5): LPA observed bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items, and paper products for residents. Water temperature was tested at an average of 106 degrees to 112 degrees.

Kitchen and Dining Area: The kitchen was adequately stocked with both nonperishable and perishable foods.
The Emergency Rations were observed in the garage with a discernible supply. All can goods were observed to be unexpired. Administrator has designated a lock box for which sharp objects will be kept.

Laundry Room: is secure, including extra and secure space for the storage of cleaning solutions and laundry detergent.

Garage contains an activity room for the residents leisure. LPA observed additional secure storage space for the facility's chemicals and backyard tools.

LPA also observed posted signs throughout facility containing the house rues/policy, LTC Ombudsman, theft and loss procedures etc. Administrator explained that the residents charts and personnel files are designated to be kept secure in the Administrator office, inaccessible to residents.

LPA did not observe any potential hazards within the facility at the time of visit. The property appears to be in good repair and safe for resident use.

The Pre-Licensing Inspection is complete and the facility has no deficiencies. COMP III was completed at the conclusion of the inspection. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy was provided to Administrator, Lee Johnson.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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