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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530192
Report Date: 05/17/2024
Date Signed: 05/17/2024 09:26:00 AM

Document Has Been Signed on 05/17/2024 09:26 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DOS PALMAS RESIDENTIAL CAREFACILITY NUMBER:
365530192
ADMINISTRATOR/
DIRECTOR:		ADUBI, DAVIDFACILITY TYPE:
735
ADDRESS:13160 DOS PALMAS RD.TELEPHONE:
(909) 251-3437
CITY:VICTORIVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 0DATE:
05/17/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:David Adubi-LicenseeTIME VISIT/
INSPECTION COMPLETED:
09:35 AM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced visit to complete the Pre-licensing inspection. LPA met with Licensee, David Adubi. The fire clearance was approved on 12/12/2023 for three (3) nonambulatory clients and one (1) ambulatory client.

The facility has four (4) bedrooms, two (2) bathrooms, living room, family room, kitchen, dining room, laundry room, one attached car garage used as office, attached 2 car garage, back yard with shed. 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 114.8 and 110 degrees fahrenheit. The refrigerator and the freezer were measured within compliance. There was a locked and secured location where medication, sharps, chemicals and clients/staff files will be stored. There was non-perishable food in the pantry and perishable food in the refrigerator.

Common Sitting Areas: There is adequate seating in the common areas. The facility has a supply of activities for the clients.

Laundry Room/ Garage: The laundry room is next to the attached 2 car garage. The attached one car garage is next to bedroom #1 and is used as the office where clients/staff files will be securely stored.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DOS PALMAS RESIDENTIAL CARE
FACILITY NUMBER: 365530192
VISIT DATE: 05/17/2024
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Linens and Hygiene Supplies: An adequate supply of linens and hygiene were available.

Backyard: There is a shaded patio with no bodies of water in the backyard, one shed used for storage and a side exit on the right side of the house. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There was three charged fire extinguishers, operating smoke detectors and carbon monoxide alarm. The home does not have any firearms and ammunition.

Postings: LPA observed required postings including the house rules, 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 working land line and telephone for clients use.

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

Licensee will be notified once facility is licensed.

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

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
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