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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881229
Report Date: 01/18/2022
Date Signed: 01/18/2022 11:43:43 AM

Document Has Been Signed on 01/18/2022 11:43 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ADORA CAREFACILITY NUMBER:
361881229
ADMINISTRATOR:VANG, CHE LIYEFACILITY TYPE:
740
ADDRESS:1543 N UNIVERSITY STTELEPHONE:
(951) 442-1902
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 6CENSUS: 0DATE:
01/18/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Che Liye Vang
Arkee Linden		TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Amy Goldenberg conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate was submitted to the Central Applications Unit (CAU) on 10/15/2021. Fire Clearance was granted 11/18/2021. LPA Goldenberg observed the following:

Structure: Facility was a single story house with six (6) resident bedrooms, 2.5 bathrooms, living room, dining area, and kitchen area.
Heating/Cooling System: Central heating and air conditioning systems.
Bedrooms: All bedrooms were adequately furnished with mattress, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. Bed frames are ordered and due for delivery on 1/18/2022. LPA verified order online.
Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by LPA at 112 F. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments have allocated locked spaces. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.
Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.
Yards/Outside: The back was completed was a patio and umbrella is ordered for shade. There were no obstructions. There were no bodies of water observed anywhere on the property.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2022
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ADORA CARE
FACILITY NUMBER: 361881229
VISIT DATE: 01/18/2022
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Garage/laundry/leisure: Laundry area with washer and dryer are available. Laundry detergents and cleaning solutions were secured. Garage was organized and free of obstructions. There was a recreational leisure area set up for staff and client use.
Emergency Phone Numbers, and Exit Plan: Let-Us-No poster and clients rights are posted.
General items: Smoke/carbon monoxide detectors were tested and operational. LPA tested facility phone and it was verified to be operational by LPA.

COMPONENT III was reviewed by the applicants during this Pre Licensing Inspection.

This facility physical plant is prepared for licensure at this time. This report was reviewed with an a copy was provided to the applicants.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
LIC809 (FAS) - (06/04)
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