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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530183
Report Date: 05/03/2024
Date Signed: 05/03/2024 12:25:52 PM

Document Has Been Signed on 05/03/2024 12:25 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:GEORGETTE ADULT RESIDENTIALFACILITY NUMBER:
365530183
ADMINISTRATOR/
DIRECTOR:		GARCIA, JEANETTEFACILITY TYPE:
735
ADDRESS:5057 AGAVE AVETELEPHONE:
(909) 641-1108
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 2CENSUS: 0DATE:
05/03/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator/Applicant George Garcia and Administrator/Applicant Jeanette Garcia TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 05/03/2024 at 09:30 AM, Licensing Program Analyst (LPAs) Melody Brown and Sarina Ramirez conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPAs met with Administrator/Applicant George Garcia and Applicant Jeanette Garcia. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 09/15/2023 for a total capacity of two (2) Ambulatory. Fire clearance was granted on 02/08/2024. LPAs Brown and Ramirez observed the following:

Structure:
Facility was a two (2) story house with two (2) client bedrooms, one (1) staff bedroom and two (2) and 1/2 bathrooms, living room, dining area and kitchen. There was an attached two (2) car garage in the left side of the house.

Heating/Cooling System:
Central heating and air conditioning system installed with one (1) central panel located in the hallway to
control entire house.

Bedrooms:
Each client bedrooms accommodate any ambulatory client. All client bedrooms were adequately furnished
with bed, chair, closet, appropriate linens, adequate lighting, a lamp and an operable smoke/carbon monoxide alarm.

Bathrooms:
The two (2) and 1/2 client/staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. LPAs Brown and Ramirez tested the water temperatures in the clients' bathrooms. ***CONTINUED ON LIC 809-C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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 3
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: GEORGETTE ADULT RESIDENTIAL
FACILITY NUMBER: 365530183
VISIT DATE: 05/03/2024
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***CONTINUED FROM LIC 809***
LPAs Brown and Ramirez verified water temperature was measured at 116 degrees Fahrenheit.

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments
were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPAs
Brown and Ramirez observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the laundry room. Laundry detergents and cleaning supplies were observed in the garage in a locked cabinet. Garage door is not locked away from clients.

Living/Family room:
There was a living/family room with adequate seating for all clients and a working TV.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the hallway of the residence.

Yards/Outside:
Patio furniture for outdoor seating observed. Self-latching handle gate on left side of the house that leads
into the backyard. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed posted near the main entrance. There was Let-Us-No poster and Labor Laws observed.

General items:
One (1) fire extinguishers was charged and located in the pantry. Three (3) combined smoke detectors and carbon monoxide detectors were tested and were observed to be in working order. Client records and staff records will be stored in a locked cabinet in the hallway. First Aid kit with required components, and locked area for medication storage was observed. LPAs Brown and Ramirez observed a facility phone and was operational as ***CONTINUED ON LIC 809-C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
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: GEORGETTE ADULT RESIDENTIAL
FACILITY NUMBER: 365530183
VISIT DATE: 05/03/2024
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***CONTINUED FROM LIC 809***
evidenced by LPAs dialing the number. The phone number designated for the facility is 909-320-8095.

There is enough Emergency water supply and the required 72-hour emergency food supply for clients and staffs available at the facility. Component III was completed on this day as well.

Additionally, LPAs Brown and Ramirez observed facility having Visitor Sign In/Sign Out Sheet and Client Sign In/Sign Out Sheet, upon entering facility.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of clients in care. Facility appears to be ready for licensure.

An exit interview was conducted, and a copy of this report, LIC809 was discussed and provided to
Applicant/Administrator George Garcia and Applicant Jeanette Garcia


SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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