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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530077
Report Date: 05/30/2023
Date Signed: 05/30/2023 10:52:34 AM

Document Has Been Signed on 05/30/2023 10:52 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:MAYFLOWER HOUSEFACILITY NUMBER:
365530077
ADMINISTRATOR:JONES JR,DR. KENNETHFACILITY TYPE:
735
ADDRESS:13634 MAYFLOWER STREETTELEPHONE:
(760) 498-6730
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 6CENSUS: 0DATE:
05/30/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Dr. Kenneth Jones Jr.TIME COMPLETED:
11:03 AM
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Licensing Program Analysts (LPAs) Ryan Gardner and Mary Rico conducted an announced visit to complete the Pre-licensing inspection. LPAs met with Licensee Dr. Kenneth Jones Jr for an Adult Residential Facility for six (6) ambulatory clients. The fire clearance was approved on 12/16/2022.

The facility is a four (4) bedroom, four (4) bath home. There are three (3) client bedrooms, one (1) staff bedroom, one (1) staff office, kitchen/dining area, two (2) living room areas, a locked laundry room, backyard, and attached garage. LPAs toured the interior and exterior areas of the facility. The following were inspected:



Client Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, and lighting.

Client Bathrooms: The bathroom appliances were operating in safe and sanitary condition. The water temperature was measured by LPA, the thermometer read at 118 degrees F.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter top were free of debris and in good repair. The refrigerator was measured at 45 degrees F and the freezer was measured at 0 degrees F.

Staff Office: The knives, sharps, and medications were safely locked and secured.

Common Sitting Areas: There is adequate seating in the common areas. The facility has a supply of activities for the clients.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2023
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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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: MAYFLOWER HOUSE
FACILITY NUMBER: 365530077
VISIT DATE: 05/30/2023
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Laundry Room/ Garage: The laundry room is near the entry to the garage. The chemicals and laundry soap were safely locked in this room.

Linens and Hygiene Supplies: An adequate supply of linens were available.

Backyard: There are no bodies of water in the backyard. There is a covered area with seating for the all the clients. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There were two (2) charged fire extinguishers in the facility. LPAs observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and ammunition.

Postings: LPAs observed required postings including the visitation polices, emergency/disaster plans, complaint procedures, and personal rights.

First aid and working telephone: The facility was equipped with a complete first aid kit and manual. The facility has working telephone for client use.

LPAs observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPAs have determined that the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete, and this facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Licensee Dr. Kenneth Jones Jr.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC809 (FAS) - (06/04)
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