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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530013
Report Date: 06/22/2022
Date Signed: 06/22/2022 10:59:13 AM

Document Has Been Signed on 06/22/2022 10:59 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
, CA 92507
FACILITY NAME:PROSPERITY SENIOR LIVING, LLCFACILITY NUMBER:
365530013
ADMINISTRATOR:SHALABI, JAMALFACILITY TYPE:
740
ADDRESS:1455 ANITA STTELEPHONE:
(337) 244-2252
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 0DATE:
06/22/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jamal ShalabiTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Rohit Lama conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:00 AM, LPA met with Administrator Jamal Shalabi . An initial application for a new facility to operate a Residential Care for the Elderly (RCFE) facility was submitted to the Central Applications Bureau (CAB) on 04/04/2022 for a total capacity of six (6) ambulatory residents. Fire clearance was granted on 5/5/2022. LPA Lama observed the following:
Structure:
Facility was a one-story house with three (3) resident bedrooms, two (2) resident bathrooms, living room, dining area, kitchen, and employee room, and an office space. There was an attached garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each resident bedroom #1, #2, and #3 (Master Bedroom) will accommodate two ambulatory residents. The three resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
The (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 9:55 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 118 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition.
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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
, CA 92507
FACILITY NAME: PROSPERITY SENIOR LIVING, LLC
FACILITY NUMBER: 365530013
VISIT DATE: 06/22/2022
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(CONTINUED FROM LIC 809)

and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the garage. Laundry detergents and cleaning supplies were observed in garage away from residents.
Living/Family room:
There was a living/family room with for all clients and TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a closet in the main hallway of the residence.
Yards/Outside:
Patio tables and six chairs were observed in the backyard. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the main hallway. Necessary signages were observed in the facility.
General items:
One (1) fire extinguishers were charged and located in the kitchen. 5 smoke/carbon monoxide alarms and one carbon monoxide detector were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the Family room. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply and 72-hour emergency food supply was observed. Component III was completed on this day as well.

Pre-Licensing is complete and no corrections are needed.
An exit interview was conducted, and a copy of this report was given.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC809 (FAS) - (06/04)
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