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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530104
Report Date: 10/10/2023
Date Signed: 10/10/2023 09:05:33 AM

Document Has Been Signed on 10/10/2023 09:05 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:
10/10/2023
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:Joseph Obadahun-LicenseeTIME COMPLETED:
09:09 AM
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On 10/10/23, Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced visit to the facility for the purpose of change of ambulatory. LPA was greeted and granted entrance by the Licensee, Joseph Obadahun.

Per the LIC200, Joseph requested from (3) ambulatory to (1) ambulatory and (2) nonambulatory on 07/24/23. The fire clearance request was approved on 09/20/2023 for (1) ambulatory client and (2) nonambulatory clients.

There is a facility sketch on file with designation of capacity and ambulatory status for each room. The licensee was advised that the noted designated capacity and ambulatory status for each room is to remain in compliance.

LPA observed that the client bedrooms were appropriately furnished and had functional lighting. The physical plant is ready for change of ambulatory. LPA will update the facility's file and issue a new license stating change in ambulatory.

There are no clients in care at the moment.

An exit interview was conducted where this report LIC809 was discussed and provided to the Licensee, Joseph Obadahun.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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