<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530247
Report Date: 12/12/2024
Date Signed: 12/12/2024 12:32:32 PM

Document Has Been Signed on 12/12/2024 12:32 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:CAPE MOUNT SPIRIT ARFFACILITY NUMBER:
365530247
ADMINISTRATOR/
DIRECTOR:		KIJAN,SADIA;KIJAN,MICHAELFACILITY TYPE:
735
ADDRESS:6547 SONOMA AVETELEPHONE:
(310) 498-9324
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 0DATE:
12/12/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Sadia KijanTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/12/2024 at 9:15 AM, Licensing Program Analysts (LPAs) Beena Singh and Melody Brown conducted an announced visit to the facility for purpose of Pre-licensing evaluation. LPAs Singh and Melody Brown met with Administrator/Applicant _Sadia Kijan and Michael Kijan. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 09/16/2020 for a total capacity of four (4) Ambulatory. Fire clearance was granted on 06/27/2024. LPAs Beena Singh and Melody Brown observed the following:

Structure:
Facility was a two (2) story house with three (3) client bedrooms, one (1) staff bedroom and three (3) bathrooms, living room, dining area and kitchen. There was an attached two (2) car garage in front 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, appropriate linens, adequate lighting, and an operable smoke/carbon monoxide alarm. However, LPAs observed no night stand in the rooms and dressers, no night lights maintained in hallways going to clients shared bathrooms. Technical Assistance issued.

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 Beena Singh and Melody Brown tested the water temperatures in the clients' bathrooms.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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 6
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: CAPE MOUNT SPIRIT ARF
FACILITY NUMBER: 365530247
VISIT DATE: 12/12/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPAs Beena Singh and Melody Brown verified water temperature was measured at 107 degrees Fahrenheit.

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments
will be secured in a locked closet located in the hallway. There was adequate room for food storage. LPAs Beena Singh and Melody Brown 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 reported to LPAs not accessible to 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 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 near the main entrance. LPAs observed no Community Care Licensing Division (CCLD) complaints poster, visitor policy, house rules, residents rights,Labor Laws observed posted in the common areas .Technical Assistance issued.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: CAPE MOUNT SPIRIT ARF
FACILITY NUMBER: 365530247
VISIT DATE: 12/12/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
General items:
Two (2) 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 Beena Singh and Melody Brown observed a facility mobile phone and was operational as evidenced by LPAs dialing the number. The phone number designated for the facility is 310-498-9324.
LPAs Singh and Brown observed there are no emergency food, water preparedness or items. Technical Assistance issued. Component III was completed on this day as well.

Pre-Licensing is incomplete and the following issues to be resolved by 01/21/2025 at 10:00 AM.
  • Obtain night stand in the rooms and dressers, night lights for each client,
  • Post CCLD Complaints poster, visitor policy, house rules, residents rights in the common areas.
  • Obtain/ purchase emergency food, water and emergency supplies.
  • Post EXIT sign on doors.

A follow-up Pre-Licensure LIC809 will be generated upon resolution of items listed above.
An exit interview was conducted, and a copy of this report, LIC809, LIC9102, were discussed and provided to
Applicant/Administrator Sadia Kijan and Administrator Michael Kijan.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6