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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530133
Report Date: 09/08/2023
Date Signed: 09/08/2023 11:33:25 AM

Document Has Been Signed on 09/08/2023 11:33 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:WINDHAVEN CARE FACILITYFACILITY NUMBER:
365530133
ADMINISTRATOR:LONDON, KEVINFACILITY TYPE:
735
ADDRESS:2724 W. WINDHAVEN DRIVETELEPHONE:
(909) 428-5959
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 4CENSUS: 0DATE:
09/08/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kevin LondonTIME COMPLETED:
11:30 AM
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Licensing Program Analyst, Amber Coleman, (LPA) conducted an announced Pre-licensing visit at Windhaven Care Facility to inspect the home prior to licensure. The LPA was greeted and granted entrance into the home by Administrator, Kevin London. Also present, staff members Sharon London and Cynthia Jones; who accompanied LPA on walk through of the facility.

Application: The application is for an Adult Residential Facility (ARF). The fire clearance has been granted for four (4) ambulatory residents. Fire clearance was approved on 6/6/23

Buildings and Grounds: The residence is comprised of 5 bedrooms, 3 bathrooms, 1 dining room, den area, kitchen, backyard and attached garage. The exterior pathways of the home were observed to be free of obstructions. Smoke and Carbon Monoxide detectors were tested and found operable. Interior passageways were clear and free of obstructions. There are no pools or other bodies of water located on the property According to Mr.London, there are no weapons stored in the residence. Rooms, furniture, beds, mattresses are all in good repair. The bedrooms are completely furnished secured windows and privacy is available. The dining and living room areas are clutter free and in good repair. The water temperature was tested and measured at 100 degrees Fahrenheit, which was within regulatory limits. Outdoor areas had sufficient room for activities and leisure. Activity supplies such as, games, and electronic were available for resident use. The washing machine and dryer were tested and found to be operable.

Storage and Supplies: Medications will be stored inaccessible to any unauthorized individuals; they will be stored in a locked cabinet in a closet. In this locked closet, secured areas are available for facility files and client funds. The First Aid kit was observed to be available and complete. Cleaning supplies will be stored away in a locked cabinet in the hall cabinet. Linens, personal hygiene supplies, and equipment are all in good repair and sufficient for approved census. Bathrooms were observed to have non-slip bath mats and grab bars available. A Fire extinguisher was available and fully charged - last inspected September 2023.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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: WINDHAVEN CARE FACILITY
FACILITY NUMBER: 365530133
VISIT DATE: 09/08/2023
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Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps will be stored in a secured cabinet in the kitchen. Chemicals and toxins kept inaccessible to residents in secure cabinet under sink.

Forms: The following forms were observed to be posted at the home: Emergency Disaster Plan (LIC 610D), Personal Rights, Facility Sketch (LIC 999), Labor laws.

The LPA will inform the Centralized Applications Bureau the home is ready for licensure. This report was discussed with and a copy provided to Mr. London.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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