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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530147
Report Date: 12/06/2023
Date Signed: 12/06/2023 11:39:06 AM

Document Has Been Signed on 12/06/2023 11:39 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:MISSION AT HOPEWELLFACILITY NUMBER:
365530147
ADMINISTRATOR:CAMPBELL, CAMILLAFACILITY TYPE:
735
ADDRESS:28358 BURNS AVE.TELEPHONE:
(909) 328-9790
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 4CENSUS: 0DATE:
12/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Fritzroy and Camilla CampbellTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Anna Bueno made an announced visit to the facility to conduct a pre-licensing inspection for an initial application. LPA Bueno identified herself to licensees Fritzroy and Camilla Campbell and informed them of the purpose of the visit.

The facility is has a pending application for an Adult Residential Facility. The facility has been granted a fire clearance on 07/25/2023 by Highland City Fire Prevention for a total capacity of four non-ambulatory clients.

The facility has a total of five bedrooms, four of which are clients', three bathrooms, kitchen, a living and family/activity area, dining room, an office area, and backyard. LPA and licensees toured the interior and exterior of the facility. The facility has no bodies of water. A covered patio allows for ample seating and outdoor activities. LPA observed that side gates were unlocked and free of obstruction. The facility had a working telephone. LPA observed a charged fire extinguisher while smoke alarms and carbon monoxide detectors were tested and found to be in working order. The facility keeps a complete first aid kit and manual. A locked centralized storage area for medications and client files was observed.

The following were observed of the physical plant:

Client Bedrooms: LPA observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting.
Client Bathrooms: LPA observed all bathrooms and fixtures are kept in sanitary conditions. LPA observed hygiene items for clients are kept locked. LPA observed night lights were maintained in the bath
Kitchen and Dining Room: LPA inspected the kitchen and found dishes, glasses, and utensils were in good working order. The dining table, kitchen countertop, appliances, and floors were free of debris. Cleaning supplies are secured and sharps are locked separately from other supplies. LPA observed appropriate food provisions. Sample menu is available for review.
Common (living/activity) areas: LPA observed adequate seating in the common areas. The facility had a supply of activities for the clients. Planned weekly activities was reviewed by LPA Bueno.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: MISSION AT HOPEWELL
FACILITY NUMBER: 365530147
VISIT DATE: 12/06/2023
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LPA Bueno observed that the physical plant is clean, in good repair, and appear to be hazard-free during today's visit. LPA 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.

An exit interview was conducted where this report was discussed and a copy was provided to Fritzroy and Camilla Campbell at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC809 (FAS) - (06/04)
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