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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530127
Report Date: 11/15/2023
Date Signed: 11/15/2023 12:07:09 PM

Document Has Been Signed on 11/15/2023 12:07 PM - 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:CHRISTIAN'S LOVE ELDERLY CARE FACILITY, LLCFACILITY NUMBER:
365530127
ADMINISTRATOR:UCHE, JULIAFACILITY TYPE:
740
ADDRESS:15336 LASSEN DRTELEPHONE:
(760) 334-8281
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 6CENSUS: 0DATE:
11/15/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Julia Uche, Licensee/AdministratorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Christian's Love Elderly Care Facility to conduct the Pre-Licensing Inspection. LPA approached the door and was greeted by Administrator/Licensee, Julia Uche. LPA introduced self and stated purpose of the visit. LPA was granted entry and provided space to work. This pre-licensing inspection is for an initial application for a Residential Care Facility for the Elderly, (RCFE). There are current no residents in care. The fire clearance/inspection was approved for six (6) residents. Four, (4) ambulatory and two, (2) non-ambulatory on 8/23/23.

The facility is a 1 level residence which is comprised of 4 bedrooms, 1 staff office, 2 bathrooms, a kitchen, Living Room, Dining Room, backyard and attached garage. There are no pools or other bodies of water located on premises. Administrator/ Licensee reports that there are no weapons or ammunition stored in the facility. Licensee provided LPA with a tour of the interior and exterior of the facility. LPA observed and inspected the following:

Resident Bedrooms: All bedrooms included appropriate mattresses with the required linens, adequate storage space for clothing and belongings, night stands, seating trash Receptacles and sufficient lighting.

Resident Bathrooms: Each bathroom was complete with non-slip grip mats on the shower, multiple grab bars, trash receptacles, and sufficient hand hygiene materials. Also, operable appliances. Licensee expressed to LPA that 1 bedroom has been designated to serve as a staff office; which can be secured. In this office were secured file cabinets which will be used to maintain resident, staff and facility files.

Kitchen and Dining Areas: LPA observed the kitchen contained functional appliances. The kitchen included sufficient amounts of dishware, utensils, pots and pans in good condition. LPA observed a sufficient amount of food at the facility. In addition multiple secure cabinets and drawers for medication, cleaning chemicals and sharp objects. LPA also observed a weekly food menu posted near the refrigerator for reference.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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: CHRISTIAN'S LOVE ELDERLY CARE FACILITY, LLC
FACILITY NUMBER: 365530127
VISIT DATE: 11/15/2023
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Living/Dining Room: LPA observed that the kitchen and dining rooms contained adequate seating for residents and their guests. Activity materials were also observed readily available to residents.

Laundry Space: The facility's washer and dryer are located in a space near the garage door. Washer and dryer in working order. Above the appliances are built in cabinets where the laundry detergent, infection control supplies, personal protective equipment. and additional cleaning solutions are kept. LPA observed that cabinet doors above the washer and dryer were also securable.

Backyard: There is a covered area which offers sufficient seating for residents and families. All passageways were free of clutter and obstructions.

Hallway closets - LPA observed that the facility included 2 closets in the hallway. One closet is designated to securely store medications and a secure refrigerator to store medications which may require refrigerated storage. Also stored in this closet was the first aid kit.

LPA observed night-lights through the facility in hallways and resident rooms. Licensee tested the smoke and carbon monoxide alarms; which were found functional. LPA observed a fully charged fire extinguisher in the kitchen. Fire extinguisher last inspected September 2023.

Near the front door of the facility, LPA observed a station, which included posters such as Resident Rights, Resident Council, LET-US-KNOW, theft/loss policy as well as the facility evacuation plans, emergency phone numbers and federal labor laws.

LPA observed required postings including the visitation polices, emergency/disaster plans, and personal rights. The facility was equipped with a complete first aid kit and manual. The facility had a working telephone for client use. The water temperature was tested and observed to be between 105-108 degrees Fahrenheit.

Overall, the facility is orderly, in good repair, and appears to be free of hazards. LPA has determined that the facility is meeting operational requirements for potential resident. LPA completed COMP III with Licensee at the conclusion of the inspection. The pre-licensing inspection is complete and this facility has no deficiencies. Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy was provided to Julia Uche.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC809 (FAS) - (06/04)
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