365530064-12-14-2022-56-AS-ACON-CM4NEP-20221214092413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530064
Report Date: 12/12/2022
Date Signed: 12/14/2022 09:24:27 AM

Document Has Been Signed on 12/14/2022 09:24 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:	GOOD TIMES FAMILY HOME		FACILITY NUMBER:	365530064
ADMINISTRATOR:	BERUMEN, DIANA L.		FACILITY TYPE:	735
ADDRESS:	4485 DENVER ST.		TELEPHONE:	(909) 240-8637
CITY:	MONTCLAIR	STATE: CA	ZIP CODE:	91763
CAPACITY: 4		CENSUS:	DATE:	12/12/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Diana Berumen		TIME COMPLETED:	03:00 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	Licensing Program Analyst (LPA) Amber Coleman arrived at the Good Times Family Home to conduct an announced visit to the facility for purpose of completing a Pre-Licensing evaluation. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Unit (CAU) on 9/26/2022 for a total capacity of four. LPA Coleman observed the following: Structure: Facility is 1 story, 4 bedrooms, 3 bathrooms, living room, dining room, an office space, kitchen and garage. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: 4 bedrooms in total. 1 room is designated for a live in staff member. All rooms were adequately furnished with a bed, seating, lighting, and secure windows. Extra linens and hygiene products were also observed in each room in the closet or dresser. Each bed included adequate bedding. 2 of the rooms accommodate 1 resident while the last room accommodates 2 residents. Each room contained a fire/carbon monoxide alarm which was tested and found to be operational. **Please See Continuation Page LIC809C**

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

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: GOOD TIMES FAMILY HOME	FACILITY NUMBER: 365530064
	VISIT DATE: 12/12/2022

NARRATIVE

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Bathrooms: All three bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper and toiletries. Water temperature measured by LPA and Administrator tested at a range of 110 degrees to 115 degrees.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed in the kitchen cabinets. Knives/sharp instruments were located in a secure drawer in the kitchen. A adequate supply of food was observed in the refrigerator and pantry. Refrigerator/freezer were clean and in working conditions. There was adequate seating available for resident meals.
Laundry area was located in garage. Washer and dryer in operable condition.

Living/Family room: There is one living room located in the front of the facility. The living room included adequate seating and furniture for residents and visitors.

Linens and Hygiene Supplies: An adequate supply of linens and hygiene products were available in each of the rooms and closets located in the hall ways.

Yards/Outside: The backyard offered adequate shady patio furniture made available to residents. There were no obstructions. There were no bodies of water observed on the property.

Garage: Located on side of kitchen near the front of the facility. Garage contained the facility washer and dryer, extra PPE and cleaning supplies secure in file cabinet. Garage door has ability to be secured. Garage also contained the facility's emergency food supplies which was also observed to be adequate.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, Ombudsman poster and rights to resident and family councils posters, personal rights were posted in the designated office area.

Office Area: Located first doorway on the right. This space contained a desk, office chair, computer and a number of file cabinets in which Administrator plans to keep all personnel and resident records.

General items: The facility has smoke alarms and carbon monoxide detectors; both tested and found operational. 2 first aid kits found in kitchen and office space. LPA observed a facility phone and it was verified to be operational. Fire extinguisher located behind front door, last inspected 10/5/2022.

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, Diana Berumen.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC809 (FAS) - (06/04)

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