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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530097
Report Date: 07/26/2023
Date Signed: 07/27/2023 05:04:32 AM

Document Has Been Signed on 07/27/2023 05:04 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:NOLA HOMES IIFACILITY NUMBER:
365530097
ADMINISTRATOR:WILSON, ASIAFACILITY TYPE:
735
ADDRESS:15921 NOTRE DAME STTELEPHONE:
(310) 658-4856
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 0DATE:
07/26/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Applicant/Administrator Asia WilsonTIME COMPLETED:
01:20 PM
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On 07/26/2023 at 10:23 AM, Licensing Program Analyst (LPA) Melody Brown conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPA met with Administrator/Applicant Asia Wilson. An initial application to operate an Adult Residential Facility was submitted to the Central Applications Bureau (CAB) on 01/23/2023 for a total capacity of four (4) ambulatory clients. Fire clearance was granted on 05/01/2023. LPA Brown observed the following:
Structure:
Facility was a two (2) story house with four (4) client bedrooms, and three (3) client bathrooms, living room, dining area and kitchen. There was an attached two (2) car garage in the left side of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with two (2) central panel located in the hallway of the main floor and second floor to control each floor of the house.
Bedrooms:
Each client bedrooms accommodate ambulatory client. All client bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable combined smoke and carbon monoxide alarm.
Bathrooms:
The three (3) client/staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. LPA Brown tested the water temperatures in the clients' bathrooms. LPA verified water temperature was measured at 115 degrees Fahrenheit.

***CONTINUED ON LIC809C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: NOLA HOMES II
FACILITY NUMBER: 365530097
VISIT DATE: 07/26/2023
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Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a medicine closet. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the hallway at the second floor. Laundry detergents and cleaning supplies were observed in the storage closet at the second floor and locked away from clients.
Living/Family room:
There was a living/family room with adequate seating for all clients and a working TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the hallway upstairs of the clients.
Yards/Outside:
Patio furniture for outdoor seating observed. There is a self-latching gate on the right side of the home that leads into the backyard. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the main level and second level hallway dining room. There was a Let-Us-No poster observed but no Ombudsman poster at the home. Applicant/Administrator Wilson reported to LPA Brown that Ombudsman Poster will be requested today.
General items:
Two (2) fire extinguishers were charged and located in the downstairs hallway and upstairs hallway. Seven (7) combined smoke detectors and carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the Office Room. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 909-251-4173. There is enough Emergency water supply observed and the required 72-hour emergency food supply and 72-hour Emergency bag pack for clients were also available at the facility. Component III was completed on this day as well.

***CONTINUED ON LIC809C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: NOLA HOMES II
FACILITY NUMBER: 365530097
VISIT DATE: 07/26/2023
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Additionally, LPA observed facility to have Visitor Sign In/Sign Out Sheet and Client Sign In/Sign Out Sheet, upon entering facility. LPA observed COVID signages throughout the facility, disposable towels in bathrooms for washing hands. Moreover, LPA Brown observed activity calendar available for the clients as well.

The facility was evaluated in accordance with the California Code of Regulation (CCR), Title 22 Division 6 Chapter 6. Based on the observations and evaluation of the facility this date, the facility’s ready for licensure.
Applicant/Administrator Asia Wilson will be notified once facility is licensed.

An exit interview was conducted, and a copy of this report (LIC809) was discussed and provided with Administrator/Applicant Asia Wilson.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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