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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425640
Report Date: 06/29/2023
Date Signed: 06/29/2023 01:03:51 PM

Document Has Been Signed on 06/29/2023 01:03 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:QUALITY CARE ADULT HOME #1FACILITY NUMBER:
366425640
ADMINISTRATOR:HODGE, CHERYL RENEEFACILITY TYPE:
735
ADDRESS:12938 ARVILA DR.TELEPHONE:
(760) 245-5718
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 5CENSUS: 1DATE:
06/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Arneka Travis, Staff MemberTIME COMPLETED:
01:15 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Quality Care Adult Home #1 unannounced to conduct the Annual Inspection. LPA was greeted by staff member, Arneka Travis. LPA introduced self and stated purpose of the visit. LPA informed that staff was in the process of assisting a resident prepare for their transport to their Adult Day Program. Staff contacted Administrator, Cheryl Hodge to notify of LPA visit. Administrator agreed to meet with LPA as staff was leaving the facility when the resident leaves for their Adult Day Program.

Personnel Records/Training/and Staffing- LPA review of employee records. Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint/background clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights and training verification, and current administrator certification were all complete.

Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA began review of resident records. Two (2) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Resident Rooms - Each resident bedroom can accommodate any ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. Including personable effects / touches for each room.



Bathrooms: All bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Hand rails were observed near toilets and in showers/tubs. Bathrooms also observed to be clean and orderly. Facility staff take the temperature of the water provided on an everyday basis. Water temperature taken was within regulated range.

**Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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: QUALITY CARE ADULT HOME #1
FACILITY NUMBER: 366425640
VISIT DATE: 06/29/2023
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Food Service - Food prep areas are clean and organized. The facility posts a weekly food menu which offers a variety of fresh nutritional. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables food on hand.

General: Disaster drills are completed on a monthly basis. Fire Extinguisher last inspected 8/2022. Smoke/Carbon alarms were tested and found functional.

No deficiencies observed during today's visit. An exit interview was conducted where this report was discussed and provided to the Facility Representative.

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

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC809 (FAS) - (06/04)
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