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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530131
Report Date: 09/06/2023
Date Signed: 09/06/2023 11:08:17 AM

Document Has Been Signed on 09/06/2023 11:08 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:JACOB PROCARE HOME 1FACILITY NUMBER:
365530131
ADMINISTRATOR:SARROCA, ARVINFACILITY TYPE:
735
ADDRESS:13387 SUNNY RIDGE STTELEPHONE:
(626) 634-3919
CITY:HESPARIASTATE: CAZIP CODE:
92344
CAPACITY: 6CENSUS: 4DATE:
09/06/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Arvin Sarroca- AdministratorTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Michelle Echeverria , arrived at Jacob Procare Home 1, to conduct an announced Pre-Licensing visit for a change of ownership (CHOW). LPA was greeted by house manager Janno Galiste and administrator Arvin Sarroca. LPA introduced self and stated purpose of the visit. CHOW application was submitted on 08/25/23 for 6 ARF Ambulatory clients. Fire Safety Inspection clearance was granted for 6 Ambulatory clients. LPA toured the facility inside and outside and observed the following:

Structure: Facility is a one story house with four client bedrooms, one staff bedroom with bathroom, two client bathrooms, living room, family room, dining area, kitchen, pantry, laundry room, backyard and an attached two car garage.

Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.

Bedrooms: Each client bedroom accommodates one ambulatory client only. Discrepancy found on facility sketch. Per facility sketch, it states that bedroom #5 is for 2 Ambulatory clients. LPA observed that bedroom #5 is currently used for staff and does not meet licensing requirements for 2 ambulatory clients with required furnishings, therefore capacity is not approved for 6 ambulatory clients.

Bathrooms: The client bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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: JACOB PROCARE HOME 1
FACILITY NUMBER: 365530131
VISIT DATE: 09/06/2023
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Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives, sharps, detergent and chemicals are stored in a locked cabinets. There was a pantry stocked with non-perishable food and perishable food found in the refrigerator. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. Water tested in the kitchen faucet measured at 107.1 degrees fahrenheit. Laundry room has a functional washer and dryer.

Living/Family room: There was a furnished living and family room with one enclosed fireplace, board games and tv observed.

Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies stored in a cabinet.

Yards/Outside: Patio furniture, self-latching handle fencing on the right side of the house that leads into the backyard. There is no swimming pool or bodies of water observed. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan: Facility sketch, CCL complaint poster, house rules, personal rights and Emergency and Disaster Plan were observed posted in the living room.

General items: The smoke and carbon monoxide detectors were tested and are operable. There was fully charged fire extinguishers observed. Client/Staff records stored in a locked closet. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 760-488-1533.

Pre-Licensing is incomplete and the following deficiencies require to be resolved:

A new application for capacity of 4 ambulatory clients, updated facility sketch and approved fire inspection clearance for 4 ambulatory clients.



An exit interview was conducted, and this report was discussed and provided to Administrator, Arvin Sarroca.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

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

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