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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800173
Report Date: 06/15/2023
Date Signed: 06/15/2023 12:05:00 PM


Document Has Been Signed on 06/15/2023 12:05 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:MEGGINSON PLACE IIFACILITY NUMBER:
331800173
ADMINISTRATOR:RACELIS, JANETTEFACILITY TYPE:
740
ADDRESS:11330 LOMBARDY LANETELEPHONE:
(951) 363-8767
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:6CENSUS: 6DATE:
06/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Caregiver Roberto DucusinTIME COMPLETED:
12:15 PM
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On Thursday, 6/15/2023, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced required annual visit to the facility at 11:00 a.m. LPA met with Administrator, Janette Racelis who was informed of the purpose of the visit. At the time of the visit, there were six (6) residents, and two (2) staff present at the facility. The facility is made up of a one-story home with 5 resident bedrooms and 3 bathrooms and an attached garage. LPA conducted a tour of the interior and exterior, and reviewed facility documents. LPA observed the following:

Bedrooms: Resident bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Resident bathrooms have a working toilet, wash basin, and were equipped with a grab bar in showers. LPA tested water temperatures in resident bathrooms and water temperatures were measured at 109-, 114-, and 116-degrees Fahrenheit. The facility has plenty of clean towels, blankets, and linen, available in different colors for each resident.

Kitchen: LPA observed a sufficient supply of dishes, glasses, utensils, pots, and pans. LPA observed knives/sharp instruments were secured in a locked cabinet drawer. Sample menu is posted on kitchen wall along with an activity schedule. The stove is operational. Refrigerator and freezer were in working condition and had plenty of perishable and non-perishable food available for the residents. Two (2) fire extinguishers were charged and mounted near kitchen counter top.

Centrally Stored Medications: LPA observed a first aid kit with required components, and locked area for medication storage.

Continued on LIC809-C

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MEGGINSON PLACE II
FACILITY NUMBER: 331800173
VISIT DATE: 06/15/2023
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Living/Family room: The family room had a working television. Let-Us-No poster, Personal Rights posters, emergency phone numbers, and facility sketch were posted in the kitchen/family room area. Hallways were free of obstructions.

Yard/Outside Area: Covered patio seating is available for all residents. All outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

Garage(s): Emergency food, water, PPE supplies and laundry washer and dryer are stored in the garage. Laundry detergent, cleaning solutions and chemicals were secured and locked in the garage.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations. An exit interview to review this report was conducted with Administrator Racelis who received a copy of this report.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
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