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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530069
Report Date: 02/14/2023
Date Signed: 02/14/2023 12:21:16 PM

Document Has Been Signed on 02/14/2023 12:21 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:GRAPHITE HOME - SALEM CHRISTIAN HOMESFACILITY NUMBER:
365530069
ADMINISTRATOR:DAWSON, SHELLYFACILITY TYPE:
735
ADDRESS:4787 GRAPHITE CREED RD.TELEPHONE:
(909) 614-0575
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
91752
CAPACITY: 4CENSUS: 0DATE:
02/14/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Shelly DawsonTIME COMPLETED:
12:25 PM
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Licensing Program Analysts (LPA) Paola Guerrero conducted an announced pre-licensing visit to facility. LPA met with Administrator Shelly Dawson. The pending application is for an Adult Residential Facility (ARF). There are currently no clients in care. The Administrator accompanied LPA on a tour of the inside and outside of the facility. The home is a four (4) bedroom, three (3) bathroom home with a living room, dining room, kitchen, attached garage. The physical plant, in general, was in good repair. The buildings and grounds are free from hazards. The 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. LPA measured and observed the water temperatures in the bathrooms to be at 104.5 degrees F. LPA observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer are maintained at appropriate temperatures. All appliances are clean and operating properly. Dishes, glasses, and utensils were in good condition. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present. The backyard is completely enclosed with functioning gate to exit to front yard. The outdoor space is suitable for client use. LPA observed fully charged fire extinguisher present in the facility. Smoke alarms and carbon monoxide are present and functional. Medications are stored and secured in a locked cabinet inaccessible to clients. The facility had a designated area for staff and client records. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There is adequate seating in the common areas. Facility had a supply of activities for the clients.

Pre-licensing inspection is complete, and no corrections are needed to be made. The Comp III presentation was completed during today's visit.

An exit interview was conducted, and a copy of this report was provided to the Administrator Shelly Dawson.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2023
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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