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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530126
Report Date: 08/24/2023
Date Signed: 08/24/2023 09:35:05 AM

Document Has Been Signed on 08/24/2023 09:35 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:SILVER ARROW RESIDENTIALFACILITY NUMBER:
365530126
ADMINISTRATOR:MENDOZA, MANUELFACILITY TYPE:
735
ADDRESS:12288 SILVER ARROW WAYTELEPHONE:
(818) 792-7055
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 0DATE:
08/24/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Manuel Mendoza-LicenseeTIME COMPLETED:
09:42 AM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced visit to complete the Pre-licensing inspection. LPA met with Licensee, Manuel Mendoza. The fire clearance was approved on 5/04/2023 for three (3) nonambulatory clients and one (1) ambulatory client.

The facility has five (5) bedrooms, three (3) bathrooms, entry room, kitchen, dining room, living room, laundry room, attached garage and back yard. LPA toured the interior and exterior areas of the facility. The following were inspected:

Client Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, and lighting.

Client Bathrooms: The bathroom appliances were operating in safe and sanitary condition.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter top were free of debris and in good repair. The water temperature was measured at 118 degrees F. The refrigerator was measured at 38 degrees F and the freezer was measured at 0 degrees F. There was a locked and secured cabinet where medication will be stored, locked closet where sharps and chemicals will be stored and a locked filing cabinet where clients/staff files will be stored. There was non-perishable food inside the pantry and perishable food inside the refrigerator/freezer.

Common Sitting Areas: There is adequate seating in the common areas. The facility has a supply of activities for the clients.

Laundry Room/ Garage: The laundry room is near the entry to the garage. The chemicals, laundry soap and toiletries were safely locked in this room.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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: SILVER ARROW RESIDENTIAL
FACILITY NUMBER: 365530126
VISIT DATE: 08/24/2023
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Linens and Hygiene Supplies: An adequate supply of linens was available.

Backyard: There are no bodies of water in the backyard. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There was one charged fire extinguisher, operating smoke detectors and carbon monoxide alarm. The home does not have any firearms and ammunition.

Postings: LPA observed required postings including the visitation policies, emergency/disaster plans, complaint procedures, and personal rights.

First aid and telephone: The facility was equipped with a complete first aid kit and emergency kits. The facility has a working land line and telephone for clients use.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22. Based on the observations and evaluation of the facility this date, the facility is ready for licensure. Component III was completed.

Licensee will be notified once facility is licensed.

An exit interview was conducted, and a copy of this report LIC809 and LIC809C were discussed and provided with Licensee, Manuel Mendoza.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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