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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425640
Report Date: 07/25/2024
Date Signed: 07/25/2024 01:41:20 PM

Document Has Been Signed on 07/25/2024 01:41 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/
DIRECTOR:		HODGE, CHERYL RENEEFACILITY TYPE:
735
ADDRESS:12938 ARVILA DR.TELEPHONE:
(760) 245-5718
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 5CENSUS: 3DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Misschellay Thompson-StaffTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Misschellay Thompson, and introduced self and stated purpose of the visit. LPA was informed that there is one client in care who is about to leave to day program and two in day program.

The facility has 4 bedrooms, 2 bathrooms, kitchen, dining area, family room, living room, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of facility, review of records, medication and P&I 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 73 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 107 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept secured and inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were observed secured and inaccessible to clients. The facility had emergency kits for clients in care. There are no pools, bodies of water, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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: 07/25/2024
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Yards/Outside: LPA observed 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.

Record Review: LPA reviewed 2 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I funds and medications were audited and appeared to be managed appropriately. The facility last conducted a disaster drill on July 3, 2024.

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 Administrator, Regina Scott who arrived 10 minutes after LPA's arrival.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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