331800154-4-24-2023-18-AS-JARA-CR7VKD-20230424163011

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800154
Report Date: 04/24/2023
Date Signed: 04/24/2023 04:30:23 PM

Document Has Been Signed on 04/24/2023 04:30 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
RIVERSIDE, CA 92507

FACILITY NAME:	CASA ALISA		FACILITY NUMBER:	331800154
ADMINISTRATOR:	ALCOCER, PETER K		FACILITY TYPE:	735
ADDRESS:	15849 ALISA VIEJO COURT		TELEPHONE:	(714) 448-0533
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY: 4		CENSUS: 3	DATE:	04/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:49 PM
MET WITH:	Administrator, Peter Alcocer		TIME COMPLETED:	04:40 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 4/24/2023 at 01:49 p.m. LPA was granted entry and met with staff, Michael Larry who was informed of the purpose of the visit. The administrator, Peter Alcocer arrived at the facility after LPA who was also informed of the purpose of the visit. At the time of the visit there was (3) staff and (1) clients present.

The facility is a two story home with (5) bedrooms and (4) bathrooms for clients. The clients served are adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted staff and client interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures.

Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Facility yard had empty soda cans that needed to be disposed of and technical note was documented for this. Fixtures and furniture were in good repair were present. Laundry room was observed, where equipment was observed to be operational. The facility cleaners were also stored in the laundry room.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the required 2-day supply of perishable and 7-day supply of non-perishable foods were low at the beginning of the visit and were informed that staff bring groceries on Mondays. Staff replenished the food supply by the end of the visit. LPA also observed expired foods in one of the facility refrigerators. LPA documented technical advisory note for this.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients. Floor plans, telephone numbers and personal rights were found in the facility. The listed administrator, possesses an administrator certificate that they have paid for a renewal as the expiration date was 4/11/2023.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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 4

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
RIVERSIDE, CA 92507

FACILITY NAME: CASA ALISA	FACILITY NUMBER: 331800154
	VISIT DATE: 04/24/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Record Review and Resident/Staff Files: LPA reviewed (3) staff files and reviewed the facility's staff schedule. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a medication cabinet. LPA reviewed client medications for (3) clients and found all medication listed on medication administration log. All required labeling was found to be in place, and all medication was accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards. LPA reviewed the facility's LIC610D and how the facility plans to deal with disasters. LPA observed emergency supplies in the facility closet upstairs.

No deficiencies were cited at the tome of the visit.

An exit interview was conducted where this report was reviewed and provided to Administrator, Peter Alcocer.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4