<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530142
Report Date: 02/02/2024
Date Signed: 02/02/2024 11:55:01 AM

Document Has Been Signed on 02/02/2024 11:55 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:IVY COURT HOME CAREFACILITY NUMBER:
365530142
ADMINISTRATOR:SIMPSON, BYRONFACILITY TYPE:
735
ADDRESS:15135 IVY COURTTELEPHONE:
(760) 686-7706
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 2CENSUS: 0DATE:
02/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:TIME COMPLETED:
11:56 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Anna Bueno conducted an announced visit to conduct a pre-licensing inspection for initial Adult Residential Facility (ARF) application. LPA Bueno identified herself to licensee Byron Simpson and informed them of the purpose of the visit.

The facility has been granted a fire clearance on 09/12/2023 by the San Bernardino County Fire Department.
The facility has been granted a fire clearance for two (2) ambulatory clients.

LPA Bueno and Licensee toured the interior and exterior of the facility. The facility has five bedrooms, three bathrooms, living room, dining room, kitchen, sitting/activity area, and backyard. The facility has no bodies of water. A covered outdoor area allows for client seating and sufficient space for outdoor activities. LPA observed that side gate was unlocked and free of obstruction. The facility has a working telephone. LPA observed charged fire extinguishers. LPA and Licensee tested smoke detectors and carbon monoxide alarms and all units were found to be in working order. The facility keeps a complete first aid kit and manual. Locked cabinets will be used for centralized medications and sharps.

The following were observed of the physical plant:
Client Bedrooms: LPA and Licensee observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, storage space, chairs, and lighting. Sufficient linens and towels were observed.
Client Bathrooms: LPA observed all bathrooms and fixtures are kept in sanitary conditions. LPA observed night lights were maintained in areas near bathrooms.
Dining Area and Kitchen: LPA inspected the kitchen and found dishes, glasses, and utensils were in good working order. The dining table, kitchen countertop, kitchen appliances, and floors were free of debris. Cleaning supplies are secured and sharps are locked separately. LPA observed appropriate food provisions. A sample menu was reviewed.
Activity Area and Living Room: LPA Bueno observed adequate seating in the common areas. The facility had a supply of activities and reading materials for individuals served. The facility has a sample of weekly activities.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: IVY COURT HOME CARE
FACILITY NUMBER: 365530142
VISIT DATE: 02/02/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Bueno observed that the physical plant is clean, in good repair, and appear to be hazard-free during today's visit. LPA completed Component III and with Licensee Byron Simpson at the conclusion of the inspection.

The pre-licensing inspection is complete and this facility has no corrections to be made. 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 licensee Byron Simpson at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2