365530265-4-3-2025-56-AS-RHSL-DFDPP7-20250403112900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530265
Report Date: 04/03/2025
Date Signed: 04/03/2025 11:29:28 AM

Document Has Been Signed on 04/03/2025 11:29 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:	CONEJO CARE HOME		FACILITY NUMBER:	365530265
ADMINISTRATOR/ DIRECTOR:	SESAY, ABIJATU		FACILITY TYPE:	735
ADDRESS:	2459 CONEJO DR		TELEPHONE:	(424) 702-2078
CITY:	SAN BERNADINO	STATE: CA	ZIP CODE:	92404
CAPACITY: 4		CENSUS: 0	DATE:	04/03/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Abijatu Sesay		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

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	Licensing Program Analyst (LPA) Renese Howell-Small conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation. I met with Administrator, Abijatu Sesay. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 1/31/2025 for a total capacity of four (4) ambulatory clients. Fire clearance was granted on 12/04/2024. LPA Small observed the following: Structure: Facility is a house with four (4) client bedrooms, two (2) client bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house. Heating /Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control the entire house. Bedrooms: Master bedroom and bathroom is to be used for staff only. All bedrooms are adequately furnished with bed, chair, closet, adequate lighting. Night lights were observed in the hallway leading to clients' shared bathrooms. . Bathrooms: Both client bathrooms have working toilets, wash basin, and shower and will have an adequate supply of paper towels, toilet paper, and soap. The water temperature was measured at 107 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Renese Howell-Small
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: CONEJO CARE HOME	FACILITY NUMBER: 365530265
	VISIT DATE: 04/03/2025

NARRATIVE

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Kitchen:
The kitchen has an adequate supply of dishes, glasses and utensils, observed. Administrator will purchase pots and pans. Knives/sharp instruments will be kept in a locked cabinet in the garage. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition.

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 off the kitchen, near the garage. Laundry detergents and cleaning supplies will be kept in a locked cabinet in the garage.

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 will be purchased and stored in a cabinet in the main hallway of the residence.
Yards/Outdoors:
There is a sufficient covered seating area in the entryway of the residence. The gate on the left 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 entry area . There was one (1) fire extinguisher, two (2) carbon monoxide detectors and (9) smoke detectors which are working and in good condition.

General items:
Client records will be stored in a locked cabinet in the staff room. First Aid kit with required components are located in storage closet near the kitchen. Medication will be locked in a cabinet in the staff room. Administrator will install a telephone. Emergency water supply and food will be purchased.

An exit interview was conducted, no deficiencies were cited, but technical assistance was provided. Component III was completed during this visit and a copy of this report was reviewed and provided to Administrator Abijatu Sesay. .

According to Title 22 California Code of Regulations, Licensee/Administrator Abijatu Sesay has satisfied all of these requirements and is ready for licensure.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Renese Howell-Small
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC809 (FAS) - (06/04)

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