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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530104
Report Date: 07/23/2024
Date Signed: 07/23/2024 09:22:16 AM

Document Has Been Signed on 07/23/2024 09:22 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/
DIRECTOR:		JADA GUTIERREZFACILITY TYPE:
735
ADDRESS:13493 JUBILEE PL.TELEPHONE:
(909) 461-9622
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 3CENSUS: 0DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Jay Pierson- StaffTIME VISIT/
INSPECTION COMPLETED:
09:32 AM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted by staff Jay Pierson. LPA toured the facility inside and outside with Jay. LPA observed that there are currently no clients admitted to the facility.

The facility has 3 bedrooms, 2 bathrooms, a kitchen, dining area, living room, office area, laundry room, attached garage, and backyard. The facility is pending vendorization by Inland Regional Center. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 77 degrees fahrenheit temperature. LPA inspected clients bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. An adequate supply of linens and blankets stored in a closet in the main hallway of the residence. LPA inspected clients bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the water temperature in the bathroom faucet, which tested within regulation at 113.6 degrees fahrenheit. The facility is equipped with operating fire extinguisher, smoke detectors and carbon monoxide alarm. Posters such as; the personal rights, the CCL complaint poster, and disaster plans were posted in a common area. LPA observed that the Emergency Disaster plan was missing the last page with signature and date. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for client/staff files, first aid kit and medication. The facility had emergency kits. There are no pools, bodies of water, firearms or ammunition. Overall, the facility is clean, in good repair, and operating in safe conditions for future clients in care.

Yards/Outside:
One shaded patio furniture for outdoor seating observed. Side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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: 07/23/2024
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Food Service: Non-perishable and perishable food supply is sufficient. Dishes, cups, and utensils were also stored properly.

Record Review: LPA reviewed the staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPA observed that all staff files were not available for review. Technical violation issued.

No deficiencies and technical violations were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C and LIC9102TV were discussed and copies were provided to staff Jay Pierson.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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