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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409896
Report Date: 07/26/2023
Date Signed: 07/26/2023 02:50:51 PM

Document Has Been Signed on 07/26/2023 02:50 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:KENNETH ADULT RESIDENTIAL IIFACILITY NUMBER:
366409896
ADMINISTRATOR:CHAVEZ, SYLVIAFACILITY TYPE:
735
ADDRESS:6818 BURKE CT.TELEPHONE:
(909) 628-0434
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 6CENSUS: 4DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Rebecca Mendoza, Direct Support StaffTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required 1 year visit to the facility. LPA met with Rebecca Mendoza, Direct Support Provider (DSP) and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), license capacity of six (6) with a current census of (4) . All clients are ambulatory. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPA inspected the facility inside and out. Indoor and outdoor passageways were kept free of obstruction. Facility living room, dining room, and outdoor patio furniture is in good repair and sufficient for clients in care. The facility is maintained at a comfortable temperature of 79 degrees F. Laundry equipment and telephone service is in working condition. Facility has no outdoor bodies of water. Facility has a covered patio area and self-latching gates.

The facility has sufficient indoor and outdoor areas for planned activities. Facility activities include watching movies, puzzles, walks, day program participation, and community outings.

LPA inspected the kitchen. Facility has sufficient non-perishable and perishable food for number of clients in care. Facility food is stored in a safe and healthful manner. Facility has a weekly menu posted in the kitchen area. Facility has sufficient cups, plates and utensils for client use. Kitchen hot water temperature tested within regulation at 105 degrees F. Sharps, disinfectants, and chemicals are kept locked and inaccessible to clients in care.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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: KENNETH ADULT RESIDENTIAL II
FACILITY NUMBER: 366409896
VISIT DATE: 07/26/2023
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LPA inspected client bedrooms. Bedrooms are equipped clean mattresses, nightstands, chairs and dressers. Bedrooms have sufficient linen and lighting.

LPA inspected client bathrooms. Client bathrooms are equipped with handrails. The hot water temperature tested within regulation. Bathrooms are operating in a safe and sanitary condition.

The facility is equipped with operating carbon monoxide alarms and fully charged fire extinguisher. A Disaster Drill was conducted on 7/7/23. Facility has posted in a common area the facility sketch, personal rights, disaster plan and emergency numbers. Facility has complete first aid kits and sufficient emergency supplies. Extra linen and towels were stored in hallway cabinet. Facility has sufficient personal hygiene products for clients in care.

LPA observed client medications are kept in a safe and locked cabinet inaccessible to clients in care. Client medications were administered as prescribed.

LPA reviewed (3) client files and all had the required documentation including admission agreements, Individual Program Plan (IPPs), physician reports. LPA reviewed (3) staff files and all had the required documentation including criminal record clearance, training, and health screenings.

Overall, the facility is clean, in good repair, and operating in safe conditions for the well-being of clients in care. 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 Direct Support Provider at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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