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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412346
Report Date: 02/10/2022
Date Signed: 02/10/2022 05:05:54 PM

Document Has Been Signed on 02/10/2022 05:05 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KENNETH ADULT RESIDENTIAL IIIFACILITY NUMBER:
366412346
ADMINISTRATOR:CHAVEZ, JAMESFACILITY TYPE:
735
ADDRESS:12379 LORAINE AVE.TELEPHONE:
(909) 364-0137
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 6CENSUS: 6DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Licensee Sylvia Chavez TIME COMPLETED:
03:30 PM
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LPA, Bernadette Allen conducted an Annual Licensing inspection. LPA was granted entry into the facility by caregiver Lorena Garcia, who contacted administrator Sylvia Chaves of the visit. Sylvia was informed of the purpose for today’s visit, was to inspect the facility to ensure the facility follows rules and regulations of California Code of Regulations. LPA conducted a general overall inspection, which included, but was not limited to, the following: physical plant; interior and exterior and records review. A tour of the facility was conducted inside and out of the home.

Licensee is providing consumer with clean linen, is in good repair, and maintains sufficient hygiene products for personal use. Smoke detectors and carbon monoxide unit are operable. The last fire drill was conducted on 2/1/2022 and earthquake drill was conducted on 1/4/2022. Hot water temperature was measured at 104.3 degrees. The facility is stocked with a 3-day supply of perishable and a 7 supply of non-perishable food items. Food is being prepared and stored properly. Medications are stored in a locked administered according to the label instructions. Pool is locked.

Sufficient staff are employed and present in the facility to meet the needs of the consumers in care. All staff have a criminal record clearance. Staff present had a 1st aid certificate available.

Based on today's inspection, no deficiencies were observed at this time in the areas evaluated.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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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