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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530216
Report Date: 10/31/2024
Date Signed: 10/31/2024 11:23:08 AM

Document Has Been Signed on 10/31/2024 11:23 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:EZRA HOMEFACILITY NUMBER:
365530216
ADMINISTRATOR/
DIRECTOR:		GARCIA, JESSEFACILITY TYPE:
735
ADDRESS:13456 FERNGLEN COURTTELEPHONE:
(760) 601-7307
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 0DATE:
10/31/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:41 AM
MET WITH:Administrator, Jesse GarciaTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Renese Howell-Small conducted an announced visit to the facility for purpose of a Pre-Licensingg evaluation. I met with Administrator, Jesse Garcia . An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 1/16/2024 for a total capacity of four (4): three (3) ambulatory and one (1) non-ambulatory. Fire clearance was granted on 04/09/2024. LPA observed the following:

Structure:
Facility is a house with four (4) resident bedrooms, three (3) resident bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house. Master bedroom to be used as a Media/Family Room.

Central heating and air conditioning system installed with a central panel located in the hallway on the first (1) level which controls entire house.

Bedrooms:
Master bedroom on the second (2) level to be used as Media/Family room.
All bedrooms are adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, Night lights were observed in the hallways on the first (1) and second (2) level. .

Bathrooms:
All three (3) bathrooms have working toilets, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. The water temperature was measured at 107 degrees Fahrenheit.

Kitchen:
The kitchen has adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments will be secured in a locked cabinet close to the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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: EZRA HOME
FACILITY NUMBER: 365530216
VISIT DATE: 10/31/2024
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Kitchen:
There was sufficient storage for perishable food. There was adequate seating for meals for all clients.

Laundry:
Laundry room with washer and dryer was located near the garage. Laundry detergents and cleaning supplies were observed in the locked closet off the ktichen and across from the dining room.

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

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


Yards/Outdoors:
There is sufficient covered seating area in the backyard. There is a gate on the leftt side will be used for garden boxes. The gate on the right side is the exit and is self-latching. All outdoor pathways were free of obstructions.

Emergency Phone Numbers and Exit Plan:
Facility sketches were observed posted in the main office area . There were three (3) fire extinguishers and two (2) carbon monoxide detectors and two (2) smoke detectors which are working and in good condition.

General items:
Client records will be stored in a locked cabinet in the kitchen area. First Aid kit with required components are located in kitchen cabinet. Medication will be locked in a cabinet in living/dining area. LPA observed a facility phone and it was verified to be operational. Emergency water supply and food was observed.

An exit interview was conducted, no deficiencies were cited, Component III was completed during this visit and a copy of this report was reviewed and provided to Administrator Jesse Garcia. .

According to Title 22 California Code of Regulations, Licensee/Administrator Jesse Garcia has satisfied all of these requirements and is ready for licensure.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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