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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530104
Report Date: 06/09/2023
Date Signed: 06/09/2023 11:53:14 AM

Document Has Been Signed on 06/09/2023 11:53 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:JUBILEE HOMEFACILITY NUMBER:
365530104
ADMINISTRATOR:ADUBI, DAVIDFACILITY TYPE:
735
ADDRESS:13493 JUBILEE PL.TELEPHONE:
(909) 461-9622
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 3CENSUS: 0DATE:
06/09/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:David Adubi TIME COMPLETED:
11:55 AM
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Licensing Program Analyst, Mary Rico, (LPA Rico) and LPM Efren Malagon arrived at the Jubilee Home Adult Residential Facility at 9:30am, as scheduled, to conduct a Pre-Licensing Visit. LPA introduced and stated purpose of the visit. Staff introduced himself as Administrator, David Adubi 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 3/23/2023.

Buildings and Grounds: The facility is a one story residence comprised of 3 bedrooms, 1 bathroom and 1 Master bathroom attach to the bedroom. Kitchen/ dining area, laundry room, living room, backyard and attached garage.
The exterior pathways of the home were observed to not be clutter free with 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. LPA observed four (4) screen windows missing and one (1) screen door missing.

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.

Mr. Adubi 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 112 degrees Fahrenheit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2023
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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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: JUBILEE HOME
FACILITY NUMBER: 365530104
VISIT DATE: 06/09/2023
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Outdoor areas included sufficient space and offers shaded patio seating. Activity materials were observed in the facility's living room.

Storage and Supplies: Medications are designated to be stored in the facility's kitchen cabin locked. The First Aid kit and manual are kept in the emergency bag packets. Linens, personal hygiene supplies, and equipment are all in good repair and sufficient for approved for the residents in care. A Fire extinguishers were observed in the kitchen fully charged and last inspected on 3/23/2023.



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 four (4) screen windows, one (1) screen door.
Clear pathway to the outdoor exit.

An exit interview was conducted this report was discussed, reviewed, then provided to Administrator David Adubi
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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