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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530070
Report Date: 03/09/2023
Date Signed: 03/09/2023 12:38:11 PM

Document Has Been Signed on 03/09/2023 12:38 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:ETERNITY LOVE RESIDENTIAL FACILITY, LLCFACILITY NUMBER:
365530070
ADMINISTRATOR:CLARKE, NOELLEFACILITY TYPE:
735
ADDRESS:14753 LADYBIRD LANDTELEPHONE:
(949) 668-5421
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 0DATE:
03/09/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Noelle ClarkeTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Victoria Chitgian conducted an announced visit to complete a pre-licensing inspection and component III. LPA met with Noelle Clarke. The application is for a Adult Residential Facility. The approved fire clearance granted four (4) ambulatory clients.

The interior and exterior was toured of the pending facility. Overall, the pending facility is clean and in good condition. LPA observed all bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, showers have non-skid mats. The hot water temperature in the kitchen was measured at 127 degrees Fahrenheit however facility has warning signage posted. LPA observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer temperatures are maintained at appropriate temperatures. All appliances are clean and operating properly. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present including an approved First Aid Manual.
LPA observed an adequate supply of recreation and leisure items and activities. The backyard is completely enclosed with functioning gate to exit to front yard. Outdoor space is suitable for client use that includes an umbrella with a table and chairs. LPA observed the fire extinguishers to be recently serviced and completely charged. Smoke alarms and carbon monoxide detectors are present and functional. Medications will be centrally stored and secured in a locked cabinet. All hazardous materials such as, cleaning, and disinfecting supplies, knives and other sharps are locked and inaccessible to clients. All required forms are posted in a common area.

Pre-Licensing Inspection and Comp III has been completed and the facility has no deficiencies or corrections.

An exit interview was conducted where this report was discussed and provided to Noelle Clarke.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023
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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