367900088-12-12-2022-19-CR-LHAS-CM2PEH-20221212101512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 367900088
Report Date: 12/12/2022
Date Signed: 12/12/2022 10:15:20 AM

Document Has Been Signed on 12/12/2022 10:15 AM - 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, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501

FACILITY NAME:	INFINITE CARE SMALL FAMILY HOME		FACILITY NUMBER:	367900088
ADMINISTRATOR:	DAHL JOHNSON		FACILITY TYPE:	710
ADDRESS:	15824 ETO CAMINO RD.		TELEPHONE:	(909) 977-9206
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92394
CAPACITY:	4	CENSUS: 0	DATE:	12/12/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Dahl Johnson		TIME COMPLETED:	10:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On December 12, 2022 at 09:04 AM, Licensing Program Analyst (LPA) Linda Haynes began a pre-licensing inspection for Infinite Care Small Family Home license. LPA met with applicant Dahl Johnson who led a tour of the home. The facility was toured both inside and out with the applicant. Currently there are no clients placed in the home. The applicant is applying to serve 4 clients ages 3 to 17. The home is a two story building with five bedrooms and three bathrooms which are set up as follows: · Bedroom #1 (Master) has one bed, will sleep the licensee, and has a master bathroom. · Bedroom #2 (Client’s) was vacant had one queen bed and a master bathroom; will sleep one client. · Bedroom #3 (Client’s) was vacant, had one full bed, it will sleep one client. · Bedroom #4 (Client’s) was vacant, had one full bed, it will sleep one client. · Bedroom #5 (Client’s) was vacant, had one full bed, it will be sleep one client · A great room/living room, kitchen, dining area, three bathrooms, an attached two car garage, storage closet, and the backyard. The Client’s bedroom was arranged so that no more than one client will be in the room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate closet space for the client’s belongings. There was a smoke detector in every bedroom and a carbon monoxide smoke detector located in the living room. The five smoke detectors and the carbon monoxide detector were checked, and they were working properly. The home’s central air conditioning module was on the patio. The home’s water heater was located inside the garage. Inside the facility there was a fireplace with a gate in the front. The appliances were in working order. CONTINUED ON NEXT PAGE:

SUPERVISOR'S NAME: Cheraki Davis	TELEPHONE: (951) -782-4946
LICENSING EVALUATOR NAME: Linda Haynes	TELEPHONE: 951-897-9368
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

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, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501

FACILITY NAME: INFINITE CARE SMALL FAMILY HOME	FACILITY NUMBER: 367900088
	VISIT DATE: 12/12/2022

NARRATIVE

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The client’s files will be locked inside a cabinet in the in the dining room. There was adequate food storage space and a supply of two days of perishable foods and a week of non-perishable foods. A proper storage of all food was discussed. A trash can for storage of solid waste with a tight-fitting lid was not present. The hot water in the Master Bathroom measured to be 119.3 degrees Fahrenheit. The water temperature of the client bathroom 1 was observed to be 119 degrees Fahrenheit. The water temperature in client bathroom number 2 measured to be 119.1 degrees Fahrenheit. it was discussed with applicant to periodically check the temperature of the bathroom faucets to make sure they do not go above 120 degrees Fahrenheit.

The home’s First Aid kit was accessible the first aid kit is located by the front door. Two fire extinguishers were present in the home one was located by the refrigerator and one was located on the second story. They were observed to be properly charged but needs to be inspected by the fire department. Applicant stated there were no weapons/firearms in the home. LPA observed a swimming pool however it was filled in completely with dirt and will not be able to hold water. The backyard where clients will have access to play was completely fenced.

The following deficiencies were observed:

The required forms needed prior to operation, were not posted at the time of this inspection. (Complaint Hot line)

The fire extinguisher needs to be checked by the fire department.
Cover holes on wall by fireplace.
Trash cans with tight fitting lids for kitchen and bathrooms

The request for a license will be forwarded to Licensing Program Manager for final approval once the Plan of Corrections are cleared. Applicant will email LPA within two weeks with proof of corrections.

An exit interview was conducted. A copy of this report was provided to Dahl Johnson.

SUPERVISOR'S NAME: Cheraki Davis	TELEPHONE: (951) -782-4946
LICENSING EVALUATOR NAME: Linda Haynes	TELEPHONE: 951-897-9368
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC809 (FAS) - (06/04)

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