Facility Evaluation Report

Licensing Program Analysts (LPA) Ana Soto, conducted a announced visit to the facility for the purpose of a

Pre-Licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on

05/15/2021 for an initial license for an Adult Residential Facility to serve Adults for ages 18 - 59 years. The requested capacity is for (4) Clients, 4 - ambulatory and 0 - Non-ambulatory. Today's pre-licensing visit was conducted with Jimmy S. David, the facility Licensee.

An application was submitted to Community Care Licensing Department (CCLD) on 05/15/2021 for an initial

license for an Adult Residential Facility to serve Developmentally Disabled Adults for ages 18-59 years. The

requested capacity is for (4) clients, 4 ambulatory, 0 non-ambulatory. Structure : Facility is a five (5)

bedrooms, and two (2) full bathrooms, single story house with front porch, attached 2 car garage, back yard. The facility is a beige stucco structure with a brick gate leading to front porch, front yard landscape is in good condition. Back yard has shaded area. Signal System : No signal system in facility. Bedroom Residents : There shall be no more than two clients per bedrooms. The bedrooms are designated client bedrooms properly equipped with regulation guidelines of 1 bed, 1 chair, 1 night stand, 1 lamp and overhead lighting. The 4 bedrooms will private bedrooms for 1 client per bedroom. Bedroom 5 will be converted to an office. Staff :No bedrooms will be used for awake staff. Bathrooms: 1 full bathroom near bedrooms and 2nd bathroom in room #4. The 2 bathrooms have a working toilet and wash basin and a walk-in shower and/or tub. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads.