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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530088
Report Date: 05/23/2023
Date Signed: 05/23/2023 12:28:57 PM

Document Has Been Signed on 05/23/2023 12:28 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:JIM'S CARE LLCFACILITY NUMBER:
365530088
ADMINISTRATOR:IGE, BOLADELEFACILITY TYPE:
735
ADDRESS:15248 SUNNY POINT ST.TELEPHONE:
(909) 442-6884
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 3CENSUS: 0DATE:
05/23/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
12:30 PM
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Licensing Program Analysts, Amber Coleman (LPA Coleman) Mary Rico, (LPA Rico) arrived at the Jim's Care Adult Residential Facility at 11am, as scheduled, to conduct a Pre-Licensing Visit. LPA's introduced themselves and stated purpose of the visit. LPA's were requested to sign in and provided space to work. Staff introduced herself as Licensee, Olayinka King. Ms. King then provided LPA's with a walk through of the facility.

Application: The application is for an Adult Residential Facility (ARF). The fire clearance has been granted for three (3) ambulatory residents. Fire clearance was conducted and approved on 1/23/23.

Buildings and Grounds: The facility is a two story residence comprised of 3 bedrooms, 2 and a half bathrooms, kitchen/dinette area, laundry room, living room, backyard and attached garage.
The exterior pathways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and found operational. Interior passageways were clear and free of obstructions. LPA's observed no pool on facility premises. LPA observed sufficient furniture and lighting throughout the facility.

Resident Rooms - LPA inspected, three (3) resident bedrooms; each room included required furniture such as: mattresses, night stands, storage space, and sufficient lighting. Each bathrooms was clean, and appliances fully operational. In room #2, at approximately 11:15am, while walking through the second floor of the facility. LPA's observed the front facing window to be missing a screen.

Ms. King reports there are no weapons stored in the facility. Rooms, furniture, beds, mattresses are in good repair. The bedrooms are completely furnished and privacy is available. The dining and living room areas are clutter free and in good repair. The water temperature was tested and ranged between 98 and 105 degrees Fahrenheit, which is within regulatory limits. Outdoor areas included sufficient space and offers shaded patio seating. Activity materials were observed in the facility's living room.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
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: JIM'S CARE LLC
FACILITY NUMBER: 365530088
VISIT DATE: 05/23/2023
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Storage and Supplies: Medications are designated to be stored in the facility's dinette area inside of a secure file cabinet; inaccessible to any unauthorized individuals. The attached garage has been designated as the facility's staff office. This is were staff and resident files are designated to be maintained.
The First Aid kit was observed inside of the television entertainment center along with the extra PPE.
Cleaning supplies observed to be stored adjacent to the kitchen in a secure closet area along with the kitchen's sharp objects. Linens, personal hygiene supplies, and equipment are all in good repair and sufficient for approved for the residents in care. Bathrooms were observed to have non-slip bath mats available. A Fire extinguishers were observed in the kitchen and on the second story; fully charged and last inspected on 1/23/23.
Food Service: Sufficient amounts of utensils and dishware were observed in the kitchen cabinets. The refrigerator and stove observed to be operational.

Forms: The following forms were observed to be posted at the home: Emergency Disaster Plan (LIC 610D), Personal Rights, Facility Sketch (LIC 999), infection control, staff schedule, food menu and activity calendars.

The following items need to be corrected before approval:
Replacement of window screen in room #2.

An exit interview was conducted were this report was discussed, reviewed, then provided to Licensee, Ms. King.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC809 (FAS) - (06/04)
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