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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530053
Report Date: 12/27/2022
Date Signed: 12/27/2022 12:10:40 PM

Document Has Been Signed on 12/27/2022 12:10 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:KINDER DILIGENCE CARE, INCFACILITY NUMBER:
365530053
ADMINISTRATOR:GREEN, D'JARNETTEFACILITY TYPE:
735
ADDRESS:16492 KASOTA ROADTELEPHONE:
(800) 557-8492
CITY:APPLEY VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 2CENSUS: 0DATE:
12/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kenisha Polk and
DiJarnette Green		TIME COMPLETED:
12:17 PM
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an announced visit to the facility to conduct a pre-licensing inspection for an initial application. LPA Nickolas identified herself to licensees Kenisha Polk and
DiJarnette Green advised them of the purpose of the visit.

The facility has been granted a fire clearance on 10/03/2022 by Apple Valley Fire Protection District for a total capacity of one (1) ambulatory resident and one (1) non-ambulatory resident.

The facility has a total of five (5) bedrooms, four (4) of which are residents', three (3) bathrooms, two (2) of which are residents', a kitchen and dining area, a living room, activity areas, and backyard. LPA and Licensees toured the interior and exterior of the facility. The facility has no bodies of water. There is a shaded seating area for residents outside. The facility had a working telephone for residents use. The facility has charged fire extinguishers, smoke alarms, and carbon monoxide detector. The facility had a complete first aid kit; however the facility needs to purchase a first aide manual. A locked centralized storage area for medications. The following were observed of the physical plant:

Client Bedrooms: LPA observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting.
Client Bathrooms: LPA observed bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients.
Kitchen and Dining Area: LPA inspected the kitchen and found dishes, cups, and utensils were in good condition and stored in a safe manner.
Laundry Room: LPA observed cleaning supplies and sharps stored in the laundry room. LPA also observed cleaning supplies and sharps were kept in a safe and secured place. The cleaning supplies and sharps were stored in separate cabinets.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2022
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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