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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425143
Report Date: 03/10/2023
Date Signed: 03/10/2023 12:09:18 PM

Document Has Been Signed on 03/10/2023 12:09 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:JEREMIAH HOMEFACILITY NUMBER:
366425143
ADMINISTRATOR:NEZART, PAMELAFACILITY TYPE:
735
ADDRESS:1706 BLUE WING COURTTELEPHONE:
(909) 389-1486
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 4CENSUS: 4DATE:
03/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Nezart Jerome and PamelaTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Victoria Chitgian conducted an unannounced visit to the facility for an annual inspection. Facility is an Adult Residential Facility licensed for four (4) ambulatory clients. LPA met with licensee Nezart Jerome and Pamela.

LPA toured the facility inside and out. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review and included nutritious options. LPA toured the client bedrooms. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 1/2/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. LPA toured the client bathrooms. LPA measured the hot water temperature in the bathrooms and kitchen. The hot water temperature measured within required limits between 107-111 degrees Fahrenheit. LPA also observed emergency supplies in the garage. The outside of the facility had a shaded area with seating for client comfort. The facility does not have bodies of water.

LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. Licensee has secured each consumer’s personal property and cash resources. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care.
Based on the observations made during todays visit, no deficiencies were issued. An exit interview was conducted where this report was discussed and provided to the licensee Nezart Jerome and Pamela.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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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