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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530325
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:23:53 PM

Document Has Been Signed on 01/16/2025 02:23 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:JESSICA VEGA GROUP HOMEFACILITY NUMBER:
365530325
ADMINISTRATOR/
DIRECTOR:		VEGA, JESSICAFACILITY TYPE:
735
ADDRESS:13641 ZIRCON WAYTELEPHONE:
(760) 243-7542
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 2CENSUS: 2DATE:
01/16/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Administrator, Jessica VegaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 01/16/2025 at 1:05PM Licensing Program Analyst (LPA) Renese Howell-Small conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation. LPA met with Administrator, Jessica Vega An initial application to operate an Adult Residential Facility was submitted to the Central Applications Bureau (CAB) on 12/18/2024 for a total capacity of (2) two ambulatory clients. Fire clearance was granted on 01/07/2025. LPA Small observed the following:

Structure:
Facility is a house with two levels and five (5) bedrooms, three (3) 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 two (2) central panels located in the hallway to control the first (1) and second (2) level.

Bedrooms:
All bedrooms for clients are adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and nighltights were observed throughout the hallway on the second 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 an adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked laundry room. 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: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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: JESSICA VEGA GROUP HOME
FACILITY NUMBER: 365530325
VISIT DATE: 01/16/2025
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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 secured in locked laundry room.

Living /Family Room:
There were two areas for 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 on the second level.

Yards/Outdoors:
There is sufficient covered seating in the backyard. There were two (2) gates on the right side and left side of the property with a self-latching handle. All outdoor pathways were free of obstructions.

Emergency Phone Numbers and Exit Plan:
Facility sketches were observed posted in the main hallway. There were two (2) fire extinguishers and two (2) carbon monoxide detectors which are in good condition, one (1) on each level.

General items:
Client records will be stored in a locked cabinet, above work station in the kitchen area. First Aid kit with required components are located in a closet in the dinning area. Medication will be locked in a closet in living/dinning area. LPA observed a facility phone and it was verified it 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, Jessica Vega. .

According to Title 22 California Code of Regulations, Administrator Jessica Vega 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: 01/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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