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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530189
Report Date: 01/05/2024
Date Signed: 01/05/2024 12:13:14 PM

Document Has Been Signed on 01/05/2024 12:13 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HOME LIVING, LLCFACILITY NUMBER:
365530189
ADMINISTRATOR:SAMSON, JESILINE CFACILITY TYPE:
735
ADDRESS:14292 BERLINA ROSE STTELEPHONE:
(760) 669-0657
CITY:HESPERIASTATE: CAZIP CODE:
92344
CAPACITY: 4CENSUS: 0DATE:
01/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jesiline Samson-LicenseeTIME COMPLETED:
12:28 PM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced visit to complete the Pre-licensing inspection for a change of location. LPA met with Administrator Jesiline Samson. The fire clearance was approved on 11/29/2023 for four (4) ambulatory clients.

The facility has four (4) bedrooms, three and half (3.5) bathrooms, one (1) staff office, kitchen, dining room, formal dining room, living room, family room, laundry room, theater room for staff utilization, inside patio, backyard, and attached garage. LPA toured the interior and exterior areas of the facility. The following were inspected:

Client Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, and lighting.

Client Bathrooms: The bathroom appliances were operating in safe and sanitary condition.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter top were free of debris and in good repair. The water temperature was measured at 113.0 degrees F. There was a locked and secured cabinet where medication and sharps will be stored. There was also non-perishable food inside the pantry and perishable food inside the refrigerator/freezer.

Staff Office: There is a safely locked and secured filing cabinet where clients and staff files are going to be stored.

Common Sitting Areas: There is adequate seating in the common areas. The facility has a supply of activities for the clients.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HOME LIVING, LLC
FACILITY NUMBER: 365530189
VISIT DATE: 01/05/2024
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Laundry Room/ Garage: The laundry room is near the entry to the garage. The chemicals and laundry soap were safely locked in this room.

Linens and Hygiene Supplies: An adequate supply of linens was available.

Backyard & Inside Patio: There are no bodies of water in the backyard. There is a shaded area with plenty of seating for the all the clients. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There were charged fire extinguishers in the facility. LPA observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and ammunition.

Postings: LPA observed required postings including the visitation policies, emergency/disaster plans, complaint procedures, and personal rights.

First aid and telephone: The facility was equipped with a complete first aid kit and emergency kits. The facility has a functioning telephone with an active land line.

The facility was evaluated in accordance with the CCR, Title 22 California Code of Regulations. Based on the observations and evaluation of the facility this date, the facility is ready for licensure. Component III was completed on this day as well.

An exit interview was conducted, and a copy of this report LIC809 and LIC809C was discussed and provided to Administrator, Jesiline Samson.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC809 (FAS) - (06/04)
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