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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530147
Report Date: 12/17/2024
Date Signed: 12/17/2024 11:43:53 AM

Document Has Been Signed on 12/17/2024 11:43 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MISSION AT HOPEWELLFACILITY NUMBER:
365530147
ADMINISTRATOR/
DIRECTOR:		JOICE PANGKEYFACILITY TYPE:
735
ADDRESS:28358 BURNS AVE.TELEPHONE:
(909) 362-5996
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 4CENSUS: 4DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Staff Maria PattipeilohyTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with staff Maria Pattipeilohy and was granted entry to the facility. The facility is a (5) bedroom (3) bathroom home and with a kitchen/dining area, living room and attached garage. The facility is an Adult Residential Facility (ARF) level 4I designated home vendor by Inland Regional Center. Licensed capacity is (4) current census (4). LPA was accompanied by Licensee Camilla Campbell to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature at 71 degrees. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 115 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated office for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. First aid kit and book were observed.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed (2) client files for admission agreements, updated physician reports, and needs and services plans. LPAs reviewed (2) client medications and (2) P&I. LPA also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MISSION AT HOPEWELL
FACILITY NUMBER: 365530147
VISIT DATE: 12/17/2024
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Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) and (LIC809C) was discussed and provided to Licensee Camilla Campbell

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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