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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366405731
Report Date: 10/09/2024
Date Signed: 10/09/2024 04:18:36 PM

Document Has Been Signed on 10/09/2024 04:18 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:GERONA ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
366405731
ADMINISTRATOR/
DIRECTOR:		JONATHAN B. GERONAFACILITY TYPE:
735
ADDRESS:14519 PONY TRAIL ROADTELEPHONE:
(760) 955-8567
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 6CENSUS: 5DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Chenier Gerona- StaffTIME VISIT/
INSPECTION COMPLETED:
04:32 PM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff Chenier Gerona introduced self and stated purpose of the visit.

The facility has 5 bedrooms, 3 bathrooms, kitchen, dining room, living room, family room, laundry room, attached garage, and backyard. LPA completed a walk through of the 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 80 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA observed a bedroom window screen missing. Technical violation issued. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 117.9 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher, and first aid kit. Posters such as; the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. Chemicals, toxins, sharps, medications and other dangerous items were kept in secure cabinets inaccessible to clients. Clients/Staff files and P&I were observed locked and made inaccessible. There are no firearms, ammunition, swimming pool or bodies of water in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Food Service: LPA observed 2 days of perishables and 7 days non-perishables food. Facility has a variety of food available. Dishes, cups, and utensils were stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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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: GERONA ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 366405731
VISIT DATE: 10/09/2024
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Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P& I was audited and matched with record.

No deficiencies and one technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, and LIC9102TV were discussed and copies were provided to Staff, Chenier Gerona.

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

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
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