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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800088
Report Date: 03/21/2023
Date Signed: 03/21/2023 02:28:31 PM

Document Has Been Signed on 03/21/2023 02:28 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:STEWART'S RESIDENTIAL CAREFACILITY NUMBER:
331800088
ADMINISTRATOR:STEWART, REUBENFACILITY TYPE:
735
ADDRESS:3631 MARI DRIVETELEPHONE:
(562) 682-0946
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 4CENSUS: 3DATE:
03/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Designee Agbelusi AdegboyegaTIME COMPLETED:
02:45 PM
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 Licensing Program Analyst (LPA) Victoria Chitgian arrived unannounced to conduct a visit to the facility for a required annual inspection. Facility is an Adult Residential Facility licensed for four (4) ambulatory clients. LPA was greeted and granted entry by the Administrator Designee (AD), Agbelusi Adegboyega at the facility.
LPA conducted a walk-through the facility's interior and exterior. The facility has a charged fire extinguisher, operating fire alarm systems, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review and included nutritious options. LPA toured the client bedrooms. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 3/1/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Cleaning supplies were stored in the garage locked away. Centrally stored medications were kept in a safe and locked cabinet. Sharps were stored in a secured area. LPA toured the bathrooms and kitchen. Hot water temperature was measured in the bathrooms and kitchen and was found above required limits however had a required "Caution hot water" sign. All required postings were visible in a common area. The outside of the facility had a shaded area with seating for client comfort. The facility does not have bodies of water.
LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA inspected client medications. Medications were dispensed appropriately according to the physician's orders. (AD) has secured each consumer’s personal property and cash resources. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care.
No deficiencies were issued during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to the (AD) Agbelusi Adegboyega at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2023
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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