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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530273
Report Date: 10/24/2024
Date Signed: 10/24/2024 04:08:43 PM

Document Has Been Signed on 10/24/2024 04:08 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:JOYSTAR ASSISTED LIVING LLCFACILITY NUMBER:
365530273
ADMINISTRATOR/
DIRECTOR:		LI, JIAQIFACILITY TYPE:
740
ADDRESS:7449 CENTER AVETELEPHONE:
9095799681
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY: 5CENSUS: 0DATE:
10/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Jiaqi Li, ApplicantTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 10/24/2024 at 1:35 PM, Licensing Program Analyst (LPA) Eldin Serrano conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPA met with Applicant Jiaqi Li. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 06/22/2024 for a total capacity of five (5) of which five (5) can be nonambulatory. Fire clearance was granted on 09/25/2024 for five (5) non-ambulatory residents. LPA Serrano observed the following:

Structure:
Facility was a one (1) story house with four (4) resident bedrooms, two (2) bathrooms, living room, dining area/kitchen and laundry. There was an attached two (2) car garage in the left side of the house.

Heating/Cooling System:
Central heating and air conditioning system installed with one (1) central panel located in the hallway to
control entire house.

Bedrooms:
Each resident bedrooms accommodate any nonambulatory residents. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, nightstands, a lamp and an operable smoke/carbon monoxide alarm.

Bathrooms:
The two (2) resident/staff bathrooms have a working toilet, wash basin, grab bars, non-slip mat and shower with an adequate supply of toilet paper and soap. LPA Serrano tested the water temperatures in the residents' bathrooms. ***CONTINUED ON LIC 809-C***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: JOYSTAR ASSISTED LIVING LLC
FACILITY NUMBER: 365530273
VISIT DATE: 10/24/2024
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***CONTINUED FROM LIC 809***
LPA Serrano verified water temperature was measured at 113.3 degrees Fahrenheit.

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments
were secured in a locked closet by the kitchen. There was adequate room for food storage. LPA Serrano observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the laundry room. Laundry detergents and cleaning supplies were observed in a locked cabinet. Garage door is locked away from residents.

Living Room:
There was a living/family room with adequate seating for all clients and a working TV.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the hallway of the residence.

Yards/Outside:
Patio furniture for outdoor seating observed. Self-latching handle gate on left side of the house that leads
into the backyard. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed posted near the main entrance. There was Let-Us-No poster.

Dementia Care Plan:
LPA Serrano observed and reviewed the Dementia Care Plan during the visit.

General items:
One (1) fire extinguisher was charged and located in the kitchen. Five (5) combined smoke detectors and carbon monoxide detectors were tested and were observed to be in working order. Resident records and staff records will be stored in a locked cabinet in the kitchen. First Aid kit with required components, First Aid Book and locked area for medication storage was observed. LPA observed a facility phone and was operational as ***CONTINUED ON LIC 809-C***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: JOYSTAR ASSISTED LIVING LLC
FACILITY NUMBER: 365530273
VISIT DATE: 10/24/2024
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***CONTINUED FROM LIC 809***
evidenced by LPAs dialing the number. The phone number designated for the facility is (909) 870-6352.

There is enough Emergency water supply and the required 72-hour emergency food supply for residents and staffs available at the facility. Component III was completed on this day as well.

Additionally, LPA Serrano observed facility having Visitor Sign In/Sign Out Sheet and Client Sign In/Sign Out Sheet, upon entering facility.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of clients in care. Facility appears to be ready for licensure.

An exit interview was conducted, and a copy of this report, LIC809 was discussed and provided to
Applicant Jiaqi Li.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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