366413181-6-15-2023-56-AS-MECA-CSTPLB-20230615112427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366413181
Report Date: 06/15/2023
Date Signed: 06/15/2023 11:24:31 AM

Document Has Been Signed on 06/15/2023 11:24 AM - 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:	SOLANA HOUSE		FACILITY NUMBER:	366413181
ADMINISTRATOR:	BYERS, MELISSA		FACILITY TYPE:	735
ADDRESS:	12279 FREEPORT DRIVE		TELEPHONE:	(760) 949-8888
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY: 4		CENSUS: 3	DATE:	06/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Melissa Byers-Administrator		TIME COMPLETED:	11:28 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/15/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Melissa Byers, introduced self and stated the purpose of the visit. LPA was informed that there is currently 1 resident in the facility and 2 residents in day program. The facility has 4 resident bedrooms, 2 bathrooms, 1 staff bedroom with private bathroom, family room, kitchen, dining area, living room, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of the facility, review of records and medication 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 75 degrees fahrenheit. LPA inspected residents bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected residents bathrooms; bathrooms were clean and appliances were functional. An adequate supply of linens and blankets stored upstairs in a cabinet in the hallway of the residence. Water temperature in kitchen faucet tested at 112.8 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, two charged fire extinguishers, first aid kit, emergency kits and emergency food. Posters such as; the personal rights, disaster plans and CCL complaint poster were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets inaccessible to residents. There was a designated storage space for resident/staff files and medications inside the locked closet. The facility has a working telephone line. There are no pools or bodies of water. Firearm and ammunition is locked in a safe made inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: SOLANA HOUSE	FACILITY NUMBER: 366413181
	VISIT DATE: 06/15/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Three refrigerators stocked with food up to date, emergency food and water were observed inside the garage. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly.

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

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. Administrator and spouse reside in the home.

Record Review: LPA reviewed 2 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed Administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff. The facility last conducted a fire and earthquake drill on May 11, 2023.

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 and LIC809C were discussed and copies were provided to the Adminstrator, Melissa Byers.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2