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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800174
Report Date: 10/04/2023
Date Signed: 10/04/2023 10:25:21 AM

Document Has Been Signed on 10/04/2023 10:25 AM - 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:DAVIS CARE SERVICES INCFACILITY NUMBER:
331800174
ADMINISTRATOR:MCCOY JR, WILLIAMFACILITY TYPE:
735
ADDRESS:40927 BELLERAY AVETELEPHONE:
(951) 239-0996
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY: 4CENSUS: 3DATE:
10/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:HOUSE MANAGER, TROUNG HOANG.TIME COMPLETED:
10:30 AM
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On October 04, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection. LPA Mixson met with House Manager, Troung introduced herself, and stated the purpose of the visit.
LPA Mixson toured the facility and inspected the inside and outside of the facility. The facility is a two story town home type facility, located at 40927 Belleray Ave, Murrieta, CA. 92562. The physical plant is clean, neat, and orderly. Outdoor and indoor passageways are free of obstruction at the time of the inspection. The facility has four bedrooms, and each room has the required furniture and storage space, and sufficient lighting. All bedrooms were equipped with the required items as per Title 22 regulations. The hot water temperature is tested monthly, and last tested within the regulations. The restrooms were equipped with liquid soap and paper towels. The LPA toured the kitchen and the living room. The kitchen area was clean, organized, and free or odors. The kitchen knives were locked and inaccessible to the residents. All food requirements were met, the seven day supply of non perishables, and the two day supply of perishable. The medications are locked in a kitchen cabinet and are inaccessible to residents. The medications are contained in bubble packs and are delivered by a pharmacy. The LPA inspected the common areas, the laundry area, and the garage. Smoke detectors were in the green and operable. The fire extinguisher was in the green, and last reviewed for services in 06/26/2023. Carbon monoxide alarms, along with smoke detectors were observed, and were operable. There were no observable Title 22, Division 6 regulation violations noticed or cited during todays visit.
An exit interview was conducted and a copy of this report, along with the LIC 811, was given to the House Manager, Troung Hoang.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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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