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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800178
Report Date: 09/09/2023
Date Signed: 09/09/2023 06:00:28 PM

Document Has Been Signed on 09/09/2023 06:00 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:THAVMA HOMEFACILITY NUMBER:
331800178
ADMINISTRATOR:SAMSON, MILAGROS VFACILITY TYPE:
735
ADDRESS:6775 MONARCH WAYTELEPHONE:
(951) 934-3563
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY: 4CENSUS: 4DATE:
09/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Rempson Samson, Administrator TIME COMPLETED:
06:08 PM
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to complete a comprehensive annual inspection. LPA Nickolas met with Administrator Rempson Samson and explained the purpose of the visit. Today’s inspection included a facility tour, record reviews, and interviews with staff. Residents in care were unable to participate in the interview process.

The facility is seven (7) and four (4) bathrooms of which three (3) bedrooms and two (2) bathrooms are used for residents in care. The facility also has great room, dining area, living room/loft area, covered patio, and attached garage. Licensed capacity is four (4), and the facility is at maximum capacity.

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility temperature is 76 degrees Fahrenheit. LPA inspected resident bedrooms; each room included required furniture such as mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were functional. LPA Nickolas' observed adequate furniture and lighting throughout the facility. The hot water temperature tested within regulation at 105 to 111.9 Fahrenheit. The facility has operating smoke detectors and carbon monoxide alarms, which LPA Nickolas tested during the visit. The facility has a charged fire extinguisher. LPA Nickolas observed personal rights posters, licensing documents, and the disaster plan posted throughout the facility. LPA Nickolas observed that cleaning supplies, toxins, sharps, and other dangerous items are kept secure and inaccessible to residents in care. There was a designated storage space for client/staff files. LPA Nickolas observed medications locked and inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient in number for residents in care. The facility has a variety of food available for clients. Dishes, cups, and utensils were also appropriately stored.

Care & Supervision: The facility staff is sufficient in number for the care and supervision of residents in care. All staff members working in the facility have criminal record clearance through the department.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2023
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: THAVMA HOME
FACILITY NUMBER: 331800178
VISIT DATE: 09/09/2023
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Record Review: LPA Nickolas reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. Medications were audited randomly and appeared to be dispensed appropriately by staff members. LPA Nickolas reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2023
LIC809 (FAS) - (06/04)
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