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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530069
Report Date: 03/20/2024
Date Signed: 03/20/2024 01:16:47 PM

Document Has Been Signed on 03/20/2024 01:16 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 ASC, 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: 3DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Randal Fowler Jr. AdministratorTIME COMPLETED:
01:19 PM
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Licensing Program Analyst (LPA) Bianca Wolcott arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by Randall Fowler Jr.(Administrator) and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. The facility has 4 client bedrooms, 3 bathrooms, kitchen, dining area, living room, laundry room, attached garage, and backyard. LPA completed a walk through of the facility and review of records.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 115 degrees within range. Grab bar rails and chair are present in the restrooms. LPA observed a locked cabinet under kitchen sink with chemicals and locked drawer with sharps. LPA observed the laundry room with locked cabinets with cleaning supplies and chemicals. LPA observed activity and food menu calendar for the month.

Fire extinguisher are charged, and mounted. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. Emergency Drills and Fire Drills are being maintained. The facility has a current written definitive plan of operation. The facility is maintained in conformity with the regulations adopted by the state fire marshal. P&I was accessed and verified by Administrator. Refrigerator is 40 degrees, and freezer is reading at -0 degrees.

Personnel Records/Training/and Staffing-. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. LPA observed First Aid Book available at facility.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GRAPHITE HOME - SALEM CHRISTIAN HOMES
FACILITY NUMBER: 365530069
VISIT DATE: 03/20/2024
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Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental- LPA reviewed resident records. Two (2) residents files & (2) staff files were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, individual personal plan (IPP), centrally stored medication, safeguard for personal property/valuables, and personal rights notification. The facility is meeting documentation requirements. Resident Rights are posted in the facility and a copy is signed on file.

Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2-day supply of perishables food on hand.



LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually, last done on 1/30/24. The facility is conducting emergency disaster drills last one done 12/11/23. Fire drills were conducted on 2/15/24.


One client was home and interviewed.

This report was reviewed with and a copy provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC809 (FAS) - (06/04)
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