331800117-12-7-2023-56-AS-MBRN-CYB3WA-20231207173625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800117
Report Date: 12/07/2023
Date Signed: 12/07/2023 05:36:34 PM

Document Has Been Signed on 12/07/2023 05:36 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	A PERFECT CHOICE FAMILY HOME		FACILITY NUMBER:	331800117
ADMINISTRATOR:	DAWSON, GARRY		FACILITY TYPE:	740
ADDRESS:	10844 MEADOW CREST CT		TELEPHONE:	(951) 406-1269
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92505
CAPACITY:	6	CENSUS: 0	DATE:	12/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	04:05 PM
MET WITH:	Administrator Garry Dawson		TIME COMPLETED:	05:45 PM

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On 12/07/2023 at 09:00 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown observed that the facility is enclosed behind a secure gate. LPA Brown contacted Administrator Garry Dawson to inform them of LPA Brown's visit. Administrator Garry Dawson agreed to meet LPA Brown at around 01:00 PM.

On 12/07/2023 at 04:05 PM, LPA Brown arrived at the facility announced to conduct a required comprehensive annual inspection. LPA Brown met with Administrator Garry Dawson, was granted entry to the facility. At the time of the visit, Administrator Garry Dawson reported to LPA Brown that there's no resident at the home.

The facility is a six (6) bedroom, three (3) bathroom home with a kitchen/dining area, living room, and attached garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents and one (1) may be bedridden and currently no residents at the facility. LPA Brown was accompanied by Administrator Garry Dawson to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility will operate in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. Bathroom showers/bathtub have a non-slip mat on the shower floor. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathroom to be at 115 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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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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: A PERFECT CHOICE FAMILY HOME	FACILITY NUMBER: 331800117
	VISIT DATE: 12/07/2023

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Cleaning supplies, toxins, sharps, and other dangerous items will be kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a cabinet where they will store the resident’s medications and locked in the medicine room area. The facility have first aid kit and a first aid manual.

Food Service: No residents at the facility. Administrator Garry Dawson reported that they will have sufficient Non-perishable and perishable food supply for the number of residents in care, once they will have residents at the facility.

Care & Supervision: The facility have an administrator present that will put sufficient hours to appropriately manage the facility. Administrator Garry Dawson reported to LPA Brown that they will hire sufficient number of staff to appropriately provide care and supervision to their residents, once they will have residents at the facility.

Record Review: LPA observed Administrator Garry Dawson updated Administrator Certification and it will expire 11/9/2025. Administrator Dawson also have updated First Aid/CPT Certification. No residents records to review as there's no resident at the facility.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), was discussed and provided to Administrator Garry Dawson..

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

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