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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530066
Report Date: 01/19/2023
Date Signed: 01/19/2023 11:50:36 AM

Document Has Been Signed on 01/19/2023 11:50 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:WE SHARE, WE CAREFACILITY NUMBER:
365530066
ADMINISTRATOR:BRYANT III, WILSON G.FACILITY TYPE:
740
ADDRESS:19196 PINE WAYTELEPHONE:
(760) 810-7059
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 0DATE:
01/19/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Wilson BryantTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Victoria Chitgian conducted an announced pre-licensing visit to the facility. LPA met with Licensee Wilson Bryant III. The pending application is for a Residential Care Facility for the Elderly (RCFE). Currently there are zero (0) residents in care. Licensee accompanied LPA on a tour of the interior and exterior of the facility. The home is a two (2) story, two (2) bedroom, three (3) bathroom with a living room, dining room, and kitchen. Upstairs area will be used as office space, storage and resident room. The physical plant, in general, was in good repair. Buildings and grounds are free from hazards. Indoor and outdoor passageways are free of obstruction. There are no pools, bodies of water, firearms or ammunition. All bedrooms are furnished with a bed, nightstand, dresser and chair. All bedrooms have adequate lighting for resident use. Bathroom’s toilet, shower and tubs are in good repair and have non-skid mats and grab bars. LPA measured and observed the water temperature in the bathrooms to be at 116 degrees F. LPA observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer are maintained at appropriate temperature. All appliances are clean and operating properly. Dishes, glasses, and utensils were in good condition. There is sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present. The exterior is enclosed with functioning gate to exit to the front yard. Outdoor space is suitable for resident use with a covered patio and bench. LPA observed full charged fire extinguisher present at the facility. Smoke alarms, carbon monoxide are present and functional. Medications are to be stored and secured in a locked cabinet inside closet. The facility has a designated area for staff and residents’ records. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There is adequate seating in the common areas. Facility has a supply of activities for residents.

Pre-licensing inspection is complete, and no corrections are needed to be made.

An exit interview was conducted, and a copy of this report was provided to the licensee Wilson Bryant III.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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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