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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530064
Report Date: 12/27/2023
Date Signed: 12/27/2023 04:21:18 PM

Document Has Been Signed on 12/27/2023 04:21 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:GOOD TIMES FAMILY HOMEFACILITY NUMBER:
365530064
ADMINISTRATOR:BERUMEN, DIANA L.FACILITY TYPE:
735
ADDRESS:4485 DENVER ST.TELEPHONE:
(909) 240-8637
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY: 4CENSUS: 0DATE:
12/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Diana Berumen, AdministratorTIME COMPLETED:
04:25 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Good Times Family Home, Adult Residential Facility, (ARF) to conduct the Annual Inspection. LPA was greeted and granted entry by Administrator, Diana Berumen. LPA introduced self and stated purpose of the visit. Administrator informed LPA that the facility has not admitted any residents yet; as the facility is pending partnership with the Inland Regional Center. LPA was accompanied by Administrator of a walk through of the facility and observed the following:

Buildings and Grounds: The facility is comprised of four bedrooms, 2 bathrooms, Living/Dining Room, Kitchen, Den (Staff Office) backyard and attached garage. Interior and exterior pathways were free of clutter and unobstructed. Fire/Smoke alarms throughout the facility are fully functional. The Fire Extinguisher found in near the front entrance is fully charged; last inspected 12/2023. There are no pools or other bodies of water located at the home. Administrator reports there are no firearms or weaponry stored in the facility.
Rooms for residents all included required furniture such as seating, sufficient lighting, adequate storage, privacy, beds, mattresses are all in good repair with proper linens. The dining and living room areas were equipped with adequate seating for residents, staff and visitors. The water temperature was tested and measured within regulatory limits. Outdoor areas had sufficient space for activities and leisure. Shade and seating available and adequate. Activity supplies such as books, magazines and puzzles were available for resident use. The washing machine and dryer were located in the garage in operable condition. Laundry detergent and chemicals are kept secure in cabinetry along side washer and dryer.
Storage and Supplies: Medications are designated be stored inaccessible to any unauthorized individuals; in the staff office in a securable file cabinets. Secured areas/space are available for staff, resident, facility files. The First Aid kit was observed to be available and complete. Cleaning supplies, sharps and chemicals are maintained in securable cabinetry in the kitchen. Linens, personal hygiene supplies, and incidentals were observed in good repair and sufficient for approved census. Bathrooms included adequate amounts of hand hygiene and paper supplies.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023
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 2
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: 12/27/2023
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Food Service: Utensils and dishware are sufficient for the requested capacity and properly stored. The refrigerator and stove are operable and in good condition. Sharps are be stored in a secured drawer in the kitchen.
Admin../Posters: The following forms were observed to be posted at the home: Emergency Disaster Plan (LIC 610D), Personal Rights, Facility Sketch (LIC 999), Labor Laws and Infection Control

Based on observations, interviews and records; no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Diana Berumen signature acknowledges understanding and receipt of report and attachments.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
LIC809 (FAS) - (06/04)
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