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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366410632
Report Date: 10/17/2023
Date Signed: 10/17/2023 12:42:17 PM

Document Has Been Signed on 10/17/2023 12:42 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:KHEESA'S FAMILY HOMEFACILITY NUMBER:
366410632
ADMINISTRATOR:THOMAS, D'ANN TFACILITY TYPE:
735
ADDRESS:17269 SAN BERNARDINO AVE.TELEPHONE:
(909) 427-0957
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: 4DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Laporsha Grant, Facility ManagerTIME COMPLETED:
12:45 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Kheesa's Family Home, unannounced to conduct an Annual Inspection. LPA introduced self and stated purpose of the visit. LPA met with Laporsha Grant, Facility Manager who provided LPA with a walk through of the facility and a space to work.

The facility is comprised of 4 bedrooms, 1 bathroom, dining room, kitchen, living room, backyard and attached garage. The facility is vendorized by the Inland Regional Center at Specialized Level. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is approved for 6 Ambulatory Adults. There are, four (4) residents in care; who were all present at time of visit. The facility is operating in the capacity approved by Community Care Licensing (CCL). Pathways on the interior and exterior of the facility were clutter free and unobstructed. The facility is maintained at a comfortable 75 degrees in temperature. LPA inspected 4 resident bedrooms; and observed that they all included the required furniture such as: mattresses and mattress covers, night stands, adequate storage space, and sufficient lighting. LPA inspected the resident bathroom; bathroom was clean with functional appliances. Bathrooms also included adequate amounts of hand hygiene supplies. LPA tested the water temperature at the kitchen faucet, which ranged from 98 to 105 degrees F . The facility is equipped with operational smoke detectors and carbon monoxide alarms. Posters such as; the personal rights and disaster plans, resident roaster, LET-US-KNOW were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items are kept secure inaccessible to residents in care. Resident and Staff files are centrally stored and made available to LPA at request. Medications are kept in a secure hallway closet inaccessible to unauthorized personnel. The facility has emergency and first aid kits readily available for residents, if needed. Overall, LPA observed the facility to be clean, in good repair, and operating in safe conditions for residents in care.
Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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: KHEESA'S FAMILY HOME
FACILITY NUMBER: 366410632
VISIT DATE: 10/17/2023
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Food Service: Non-perishable and perishable food supply is adequate for number of residents in care. LPA observed a fully stocked refrigerator with milk, eggs, bread, juice and frozen foods. LPA also observed a monthly food menu posted on the refrigerator. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.
Record Review: LPA reviewed 4 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 3 staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. LPA observed the resident's medication lists along side Medications; which appeared to be dispensed appropriately by staff members. The facility conducts fire/disaster drills on a monthly basis. LPA observed a fully charged fire extinguisher; last inspected September 2023.

Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
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