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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530209
Report Date: 10/02/2024
Date Signed: 10/02/2024 04:23:54 PM

Document Has Been Signed on 10/02/2024 04:23 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:SERENITY ON POPPYFACILITY NUMBER:
365530209
ADMINISTRATOR/
DIRECTOR:		STEWART, ZIPORAFACILITY TYPE:
735
ADDRESS:7422 POPPY CTTELEPHONE:
(626) 318-7552
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 0DATE:
10/02/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Zipora Stewart, Applicant/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 10/02/2024 at 1:15 PM, Licensing Program Analysts (LPAs) Becky Mann, Melody Brown and Renese Howell-Small conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPAs Mann, Brown and Howell-Small met with Administrator/Applicant Zipora Stewart. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 12/06/2023 for a total capacity of six (6) Ambulatory. Fire clearance was granted on 06/03/2024. LPAs observed the following:

Structure:
Facility was a two (2) story house with three (3) client bedrooms, one (1) office room and three (3) bathrooms, living room, dining area and kitchen. There's an attached two (2) car garage in the right 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 detectors.

***CONTINUED ON LIC 809-C***
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SERENITY ON POPPY
FACILITY NUMBER: 365530209
VISIT DATE: 10/02/2024
NARRATIVE
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***CONTINUED FROM LIC 809***
Bathrooms:
The three (3) client/staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. LPAs tested the water temperatures in the clients' bathrooms. LPAs observed no non-slip bath mats in client's shared bathroom. Technical Assistance issued. LPAs verified water temperature was measured at 118 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 laundry room closet. There was adequate room for food storage. LPAs 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 area. Laundry detergents and cleaning supplies were observed in the laundry room in a locked closet. Garage door is locked away from clients.

Living/Family room:
There's 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 upstairs in the hallway of the residence.

Yards/Outside:
Patio furniture for outdoor seating observed. Self-latching handle gate on right 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 in the kitchen by the back Exit door.
***CONTINUED ON LIC 809-C***
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SERENITY ON POPPY
FACILITY NUMBER: 365530209
VISIT DATE: 10/02/2024
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***CONTINUED FROM LIC 809***
General items:
Two (2) fire extinguishers were charged. There is six (6) smoke detectors and two (2) 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 office room. First Aid kit with required components, and locked area for medication storage was observed. LPAs observed no First Aid Manual/Book at the facility. Technical Assistance is issued. LPAs observed a facility phone and was operational as evidenced by LPAs dialing the number. The phone number designated for the facility is 909-251-4495.

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 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, LIC809C and LIC9102 was discussed and provided to Applicant/Administrator Zipora Stewart.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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