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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800174
Report Date: 03/22/2024
Date Signed: 03/22/2024 10:37:40 AM

Document Has Been Signed on 03/22/2024 10:37 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
RIVERSIDE ASC, 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: 2DATE:
03/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Hoang Truong, House ManagerTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility. The LPA met with Hoang Truong, House Manager, and informed him of the purpose for the visit. During the visit the LPA observed the below concerns.

The LPA observed the washing and drying machines to be removed from their operating locations and stored in the garage. According to House Manager Hoang, the washing machine stopped working yesterday, 03/21/2024.

The LPA observed a broken door leading into the bedroom of Client One (C1). According to House Manager, Hoang, C1 broke the door on 03/12/2024 during a behavior.

In addition, the LPA also observed drug paraphernalia in the bedroom of C1. According to the House Manager, Hoang Truong, C1 has a prescription for the item. House Manager agreed to lock C1's bedroom door. According to the House Manager, C1 administers the item on their own.

According to Administrator, Chris Davis, the washing machine did break yesterday, 03/21/2024. He reported a new washing machine would be purchased today, 03/22/2024. He reported the facility is currently having laundry done at a local laundry mat. He reported no notice was submitted to the Department regarding use of laundry mat services. Administrator Davis also reported a new door would be purchased today, 03/22/2024. He agreed to provide the Department with a receipt of the purchases.

This report was reviewed with House Manager, Hoang, and a copy was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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