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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400088
Report Date: 10/17/2024
Date Signed: 10/17/2024 02:03:36 PM

Document Has Been Signed on 10/17/2024 02:03 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DOUBLE J'SFACILITY NUMBER:
366400088
ADMINISTRATOR/
DIRECTOR:		GOODRICH, JANICEFACILITY TYPE:
735
ADDRESS:9363 PINON AV.TELEPHONE:
(760) 947-4723
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 0DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Janice GoodrichTIME VISIT/
INSPECTION COMPLETED:
02:07 PM
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Licensing Program Analysts (LPAs) Magda Malcore and Renese Howell-Small made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with Licensee, Janice Goodrich and discussed the purpose of the visit. The facility is an Adult Residential facility with a license capacity of (6) and a current census (0). The Licensee stated that there has not been clients since September 2024. The facility is a certified Inland Regional Center (IRC) vendor. LPAs conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: The facility is operating in the capacity approved by Community Care Licensing. Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor activity space. Outdoor activity space is shaded and enclosed with a latching gate. The facility is equipped with operating carbon monoxide alarms, laundry equipment, night lights and telephone service. The facility has a sufficient supply of bed linen, towels, and hygiene products for clients. Client bedrooms were equipped with beds, bed linen, nightstands, chairs, and bedroom lighting. Client bathrooms were operating in safe conditions. The hot water in client bathrooms tested at 110 degrees F. The facility has posted: Community Care Licensing complaint poster, emergency telephone numbers, facility sketch. The Licensee's administrator certification is current. The facility's liability insurance is current.

Food Service: The kitchen area was maintained clean. The facility has a sufficient supply of non-perishable and perishable food.

Health Related Services: The facility currently has no clients in care. LPA's observed a locked cabinet which will be used to store client medications.

Personnel/Client Records: There are no clients in care and no staff to conduct a file review.

No deficiencies were cited during today’s visit. An exit interview was conducted, where this report was discussed and a copy was provided to the Licensee at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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