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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530227
Report Date: 10/04/2024
Date Signed: 10/04/2024 01:46:32 PM

Document Has Been Signed on 10/04/2024 01:46 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JORDAN SENIOR HOMEFACILITY NUMBER:
365530227
ADMINISTRATOR/
DIRECTOR:
HUSSEIN, SHADENFACILITY TYPE:
740
ADDRESS:7051 GABELS CREST PLACETELEPHONE:
(205) 777-9144
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 0DATE:
10/04/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Shaden HusseinTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analysts (LPA) Beena Singh and Paola Guerrero conducted an announced pre-licensing visit to the facility. LPAs met with Facility Licensee .

The pending application is for a Residential Care Facility for Elderly (RCFE). Current capacity is (6). The Administrator accompanied LPAs on a tour of the inside and outside of the facility. The physical plant, in general, was in good repair. The buildings and grounds are free from hazards. The indoor and outdoor passageways are free of obstruction. LPAs observed an in-ground pool at the facility, the perimeter of the pool was gated and locked. All bedrooms are furnished with a bed, nightstand, dresser, and chair. All bedrooms have adequate lighting for resident use. Bathroom's toilet, shower and tubs are in good repair and have non-skid mats. LPAs observed food storage and preparation areas to be clean and sanitary. LPAs inspected facilities freezer and Refrigerators logs all listed appropriate temperatures according to Title 22 regulation. All appliances are clean and operating properly. The outdoor space is suitable for residents use. LPAs observed fully charged fire extinguishers present in the facility. Smoke alarms and carbon monoxide are present and functional. Facility has a designated cabinet where medications are locked and stored. There is adequate seating in the common areas. Facility had a supply of activities for the residents.

An exit interview was conducted, and a copy of this report was provided to Facility Licensee Shaden Hussein.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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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