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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530151
Report Date: 03/04/2025
Date Signed: 03/04/2025 02:33:08 PM

Document Has Been Signed on 03/04/2025 02:33 PM - 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:STAY WITH USFACILITY NUMBER:
365530151
ADMINISTRATOR/
DIRECTOR:		LOPEZ, MAYRAFACILITY TYPE:
735
ADDRESS:15432 DEL REY DRIVETELEPHONE:
(442) 242-7453
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 0DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Mayra Lopez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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On 3/4/2025 at 12:50 PM, Licensing Program Analyst (LPA) Eldin Serrano conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPA was greeted by Administrator Mayra Lopez and gained access to the home. LPA explained the purpose of the visit to Administrator Mayra Lopez.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). The facility is licensed for 4 ambulatory of which 2 maybe non- ambulatory. LPA Serrano completed a walkthrough of the facility, review of records..



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA observed no client during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 68 degrees Fahrenheit. LPA Serrano inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA Serrano inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 109.7 degrees Fahrenheit. The facility is equipped with operational smoke detectors and carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book.

Posters such as the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications will be kept in secure cabinets inaccessible to clients. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

*** Continuation in LIC809C ***

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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: STAY WITH US
FACILITY NUMBER: 365530151
VISIT DATE: 03/04/2025
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Yards/Outside: One shaded patio, two (2) side gates with self-latching handle on the both side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA Serrano observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Record Review: LPA reviewed no client files because IRC did not have any clients placed for the facility as of yet. LPA reviewed one (1) staff file for First Aid/CPR certification, emergency intervention certification (CPI), criminal record clearance,trainings, and health screenings with tuberculosis (TB) test result and observed files were complete.

No deficiency was cited during this visit. An exit interview was conducted where this report LIC809, LIC809C were discussed, and copies were provided to Administrator Mayra Lopez.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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