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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530169
Report Date: 02/16/2024
Date Signed: 02/16/2024 12:03:24 PM

Document Has Been Signed on 02/16/2024 12:03 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:MERCY MEADOWS DEVELOPMENTAL HOMEFACILITY NUMBER:
365530169
ADMINISTRATOR:PERRY, RHONESIAFACILITY TYPE:
735
ADDRESS:11320 LAWSON AVENUETELEPHONE:
(626) 708-1887
CITY:ADELANTOSTATE: CAZIP CODE:
92310
CAPACITY: 4CENSUS: 0DATE:
02/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Rhonesia Perry/Executive Director/OwnerTIME COMPLETED:
12:03 PM
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's) Bianca Wolcott and Anna Bueno conducted an announced visit to the pending facility for the purpose of conducting the pre-licensing inspection. LPA met with applicant Rhonesia Perry/Executive Director/Owner.

The LPA's toured the facility inside and out. The pending application is for four (4) non-ambulatory residents in a Adult Residential Facility. The following was observed, reviewed, and inspected: there are (2) resident bedrooms and one (1) resident bathroom. There are no bodies of water. The physical plant, in general, was in good repair. Buildings and grounds were free of hazards. Outdoor and indoor passageways were kept free of obstruction. There are charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. There is a locked area for cleaning supplies, medications, and sharps. Cleaning supplies were stored underneath the kitchen sink. Laundry room will have a cabinet with a lock for chemicals. Medications will be stored in a locked kitchen cabinet. Sharps were stored in a locked box. LPA's toured the resident bedrooms. Resident bedrooms had the required furniture, chair, bedding, and functional lighting. The facility had a supply of additional linen and extra hygiene items for the residents. LPA's toured the kitchen. Food was stored in a safe and healthful manner. The facility had a menu available for review. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. Dishes, glasses, and utensils were in good condition. The facility had a designated area for staff and resident files. LPA's toured the resident bathrooms. The bathrooms were operating in safe and sanitary conditions. LPA's observed grab bars in the shower area. LPA's measured the hot water temperature in the bathrooms. The hot water temperature measured 110 degrees F. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. The facility was equipped with a complete first aid kit (e.g. thermometer, tweezers, scissors, antiseptic, bandages, gauze). There is adequate seating in the common areas. Facility had a supply of activities for the residents. Emergency lighting (e.g. flashlights) were also maintained.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MERCY MEADOWS DEVELOPMENTAL HOME
FACILITY NUMBER: 365530169
VISIT DATE: 02/16/2024
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's Wolcott and Bueno, observed that the physical plant is clean, in good repair, and appear to be hazard-free during today's visit. LPA's completed Component III with Rhonesia Perry/Executive Director/Owner 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 Executive Director/Owner Rhonesia Perry at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2