366427383-1-27-2025-56-AS-MMAE-DDBSKT-20250127125715

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366427383
Report Date: 01/27/2025
Date Signed: 01/27/2025 12:57:25 PM

Document Has Been Signed on 01/27/2025 12:57 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:	ESPINOZA ADULT CARE HOME I		FACILITY NUMBER:	366427383
ADMINISTRATOR/ DIRECTOR:	LYDIA ESCUTIA		FACILITY TYPE:	735
ADDRESS:	14232 SAVANA STREET		TELEPHONE:	(909) 770-3544
CITY:	ADELANTO	STATE: CA	ZIP CODE:	92301
CAPACITY: 5	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	01/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Amber Espinoza		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Licensee, Amber Espinoza and discussed the purpose of the visit. The facility is an Adult Residential facility with a license capacity of (5) and a current census (4). LPA conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: The facility is operating within capacity approved by Community Care Licensing (CCL). The facility maintains a current emergency disaster plan, disaster drill, and surety bond record on file. Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility's outdoor activity space is enclosed with a latching gate. The facility has sufficient indoor activity space and supplies for clients in care. The facility is equipped with smoke/carbon monoxide alarms, fully charge fire extinguisher, laundry equipment, telephone service and is maintained at 73 degrees F. The facility has a sufficient supply of bed linen and personal hygiene products for clients in care. Four (4) client bedrooms were equipped with beds, bed linen, nightstands, chairs, storage space and lighting. Client bathroom equipment were operating in safe conditions. The hot water in client bathrooms tested at 108 degrees F. Sharps, disinfectants and cleaning supplies were kept in a locked room.

Care & Supervision: The facility has 24 hour, 7 days a week staff supervision. Staff working have criminal record clearances through the Department.

Food Service: The facility’s dining areas, kitchen, and dishware utilized by clients were maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care. The facility’s freezer temperature is maintained at zero degrees.

Health Related Services: The facility maintains records of client medications and medications are centrally stored in a locked closet.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

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: ESPINOZA ADULT CARE HOME I	FACILITY NUMBER: 366427383
	VISIT DATE: 01/27/2025

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Personnel/Client Records: Staff records were reviewed for health screenings, criminal record clearances, orientation, health screenings, CPI and first aid/CPR training certifications. Client records were reviewed for admission agreements, medical/behavioral assessments, needs and service plans, and personal/incidental logs.

No deficiencies were cited during today’s visit. An exit interview was conducted, where this report was discussed and a copy was provided to the Licensee, at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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