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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400088
Report Date: 10/04/2023
Date Signed: 10/04/2023 11:36:51 AM

Document Has Been Signed on 10/04/2023 11:36 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DOUBLE J'SFACILITY NUMBER:
366400088
ADMINISTRATOR:GOODRICH, JANICEFACILITY TYPE:
735
ADDRESS:9363 PINON AV.TELEPHONE:
(760) 947-4723
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 2DATE:
10/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Janice Goodrich- LicenseeTIME COMPLETED:
11:42 AM
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On 10/04/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Licensee, Janice Goodrich, and introduced self and stated purpose of the visit. LPA was informed that the 2 clients were in program.

The facility has 5 bedrooms, 3 bathrooms, kitchen, 2 pantry rooms, dining area, living room, laundry, backyard, detached garage and a shed. LPA completed a walk through of facility, review of records and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 70 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 105.6 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguishers and first aid kit. Posters such as; the personal rights, disaster plans and CCL complaint poster were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets and drawers inaccessible to clients. There was a designated storage space for client/staff files. Medications was observed locked and inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient. Facility has a wide variety of food available. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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'S
FACILITY NUMBER: 366400088
VISIT DATE: 10/04/2023
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Yards/Outside: One shaded patio, side gate with self-latching handle on the left and right side of the house that leads into the backyard, a detached garage and one shed found. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed Licensee file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed one client file for admission agreements, updated physician reports, and needs and services plans. P & I funds were counted at random and matched with the ledger. LPA reviewed facility's file for fire drills, infection control plan, smoke alarm servicing and insurance policy.

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 and LIC809C were discussed and copies were provided to the Licensee, Janice Goodrich.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC809 (FAS) - (06/04)
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