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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408353
Report Date: 09/28/2023
Date Signed: 09/28/2023 12:13:27 PM

Document Has Been Signed on 09/28/2023 12:13 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:JP'S RESIDENTIAL CAREFACILITY NUMBER:
366408353
ADMINISTRATOR:PIERRE, YVONNEFACILITY TYPE:
735
ADDRESS:922 W. MESA DRIVETELEPHONE:
(909) 875-6147
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 2CENSUS: 0DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Yvonne Pierre, Licensee/AdministratorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrives at the JP's Residential Facility unannounced to conduct an Annual Inspection. LPA introduced self and stated purpose of the visit. LPA met with Administrator, Yvoone Pierre who also provided LPA with a tour of the facility. LPA Coleman conducted a tour of the facility, inside and outside, and observed the following:

Facility: The Facility's current census is one. Resident was at work during, LPA visit. LPA Coleman observed that the facility is operating at the capacity and in the conditions approved by Community Care Licensing (CCL). The facility is also vendorized the Inland Regional Center, (IRC).

Physical Plant: LPA Coleman observed the facility's temperature to be comfortable. The lighting and lamps make for appropriate lighting to ensure resident's comfort and safety. The facility is equipped with smoke alarms, carbon monoxide detectors and fire extinguishers which was fully charged and operable.

Food Service: Nonperishable and perishable food is sufficient. Food is being prepared and stored properly. Facility has a variety of food available for its resident. LPA observed that although the kitchen is secure, sharps and chemicals are also kept secure inaccessible.

Care & Supervision: Facility has sufficient care staff; who is available 24 hours and 7 days a week. According to staff records, staff file contained verification of their annual training.
Record Review and Resident/Staff Files: LPA Coleman reviewed the staff file and resident record. Resident records are complete with physician reports and Needs and Services Plans. LPA confirmed that staff records reflect current CPR/First Aid Certification and Criminal Record Clearance. The Administrator's Administrator Certificate was observed in compliance.
Administration: Disaster Plan, Ombudsman poster, Administrator Certificate, Personal Rights and facility license are posted in the hallway of the facility. Emergency Disaster Plan is current.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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: JP'S RESIDENTIAL CARE
FACILITY NUMBER: 366408353
VISIT DATE: 09/28/2023
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Medication/Medical Related Services: LPA observed that the residents' medication is stored securely. LPA reviewed residents' medication list and made no observation of error or inconsistency.

No deficiencies were cited during this inspection. Exit interview conducted and copy of this report was provided to Administrator/Licensee Yvonne Pierre.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
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