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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530140
Report Date: 09/11/2023
Date Signed: 09/11/2023 11:49:17 AM

Document Has Been Signed on 09/11/2023 11:49 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:WYNDHAM HOUSEFACILITY NUMBER:
365530140
ADMINISTRATOR:OSBY, CONRADFACILITY TYPE:
735
ADDRESS:16723 WYNDHAM LNTELEPHONE:
(909) 346-0392
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 3CENSUS: 0DATE:
09/11/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Conrad and Tammy OsbyTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to complete a prelicensing inspection. LPA Nickolas met with Licensees Conrad and Tammy Osby and explained the purpose of the visit. Today’s inspection included a facility tour and records review.

The pending application is for an Adult Residential Facility (ARF). The facility has been granted a fire clearance for a total capacity of three (3) ambulatory clients by the Fontana Fire Department on
June 14, 2023.

The facility has a total of four (4) bedrooms and three (3) and a half (1/2) bathrooms of which three (3) bedrooms and two (2) and a half (1/2) bathrooms are used for residents in care. The facility also has great room, kitchen, dining area, backyard, and attached garage. The facility has no bodies of water and a shaded area for outdoor seating. The facility has a working telephone, a charged fire extinguisher, combined smoke, and carbon monoxide detectors, and a complete first aid kit. LPA Nickolas observed that cleaning supplies, toxins, sharps, medications, and other dangerous items are kept secure and inaccessible to residents in care. The following were observed of the physical plant:

Client Bedrooms: LPA Nickolas’ observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting.


Client Bathrooms: LPA Nickolas observed bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients.
Kitchen and Dining Area: LPA Nickolas inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. LPA Nickolas' also observed all kitchen appliances working and in good repair.
Common areas: LPA Nickolas' observed night lights were maintained in the hallways. There is adequate seating in the common areas.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: WYNDHAM HOUSE
FACILITY NUMBER: 365530140
VISIT DATE: 09/11/2023
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LPA Nickolas observed that the physical plant is clean, in good repair, and appear to be hazard-free during today’s visit. LPA Nickolas' has determined that the facility is meeting operational requirements for future clients. LPA Nickolas completed COMP III with the 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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC809 (FAS) - (06/04)
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