366426473-9-25-2024-56-AS-JPRO-D8CTW8-20240821150508

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426473
Report Date: 08/21/2024
Date Signed: 09/25/2024 03:55:46 PM

Document Has Been Signed on 09/25/2024 03:55 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
, CA 92507

FACILITY NAME:	KENNETH ADULT RESIDENTIAL IV		FACILITY NUMBER:	366426473
ADMINISTRATOR:	CHAVEZ, JAMES E		FACILITY TYPE:	735
ADDRESS:	4068 MIRA MESA AVE.		TELEPHONE:	(909) 342-9551
CITY:	CHINO	STATE: CA	ZIP CODE:	91710
CAPACITY:	6	CENSUS: 4	DATE:	08/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Sylvia Chavez, Administrator		TIME COMPLETED:	03:15 PM

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Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced required 1-year visit to the facility. LPA met with Sylvia Chavez and discussed the purpose of the visit.

The facility is a Adult Residential Facility (ARF), license capacity of (6) clients with a current census of (4). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPA inspected the facility inside and out. Indoor and outdoor passageways are kept free of obstruction. LPA observed outdoor pool is surrounded by a locked fence. Backyard covered patio area is sufficient for client activities. Facility has sufficient indoor space for client activities. The facility has sufficient lighting and is maintained at a comfortable temperature.

LPA observed posted client activities for the month and clients also participate in an off-site day program.

LPA inspected the kitchen. Hot water temperature tested at 110 degrees F. Facility has sufficient non-perishable and perishable food for number of clients in care. Facility food is stored in a safe and healthful manner. Facility has sufficient cups, plates, and utensils for client use.

LPA inspected client bedrooms. Bedrooms are equipped beds, linen, nightstands, chairs, sufficient storage space and lighting.

LPA inspected client bathrooms. Bathrooms are operating in safe and sanitary condition. Bathroom hot water temperatures tested between 107 to 109 degrees F.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: KENNETH ADULT RESIDENTIAL IV	FACILITY NUMBER: 366426473
	VISIT DATE: 08/21/2024

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The facility is equipped with operating carbon monoxide alarms. Fire drill was conduct on 08/05/2024 and earthquake drill was conducted on 8/13/2023.

Facility has posted the facility sketch, personal rights, disaster evacuation plan and emergency numbers. Facility has a complete first aid kit and emergency supplies, including bottled water and back-up generator. Facility has sufficient supply of linen, towels, and hygiene products for clients in care. Sharps, disinfectants, and chemicals are kept locked and inaccessible to clients in care.

LPA inspected client medications. Medications are labeled and administered as prescribed. Medications are kept locked and inaccessible to clients in care.

LPA reviewed client files for admission agreements, Individual Program Plan (IPPs), physician reports and record of client valuable resources, all had the required documentation.

LPA reviewed staff files for criminal record clearances, first aid certifications, training, and health screenings, all had the required documentation.

An exit interview was conducted, where this report was discussed and a copy was provided to the Administrator, at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC809 (FAS) - (06/04)

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