331800240-4-25-2023-18-AS-CNWE-CR92BL-20230425171520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800240
Report Date: 04/25/2023
Date Signed: 04/25/2023 05:15:27 PM

Document Has Been Signed on 04/25/2023 05:15 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:	PERRY'S RESIDENTIAL FACILITY, INC		FACILITY NUMBER:	331800240
ADMINISTRATOR:	ADAMS, ANDY		FACILITY TYPE:	735
ADDRESS:	13141 WINDSONG ROAD		TELEPHONE:	(951) 455-4114
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY: 5		CENSUS: 4	DATE:	04/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Andy Adams, Administrator		TIME COMPLETED:	05:25 PM

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On 04/25/2023, Licensing Program Analysts (LPAs) Chinwe Nwogene and Janette Romero arrived unannounced at the facility to conduct an annual inspection. LPAs was greeted and granted entry by Facility Manger/caregiver, Otira Caldwell. Otira called the Administrator, Andy Adams who arrived at the facility shortly after. At the time of visit there was two #2 staff and three #3 residents present. LPAs toured the facility inside and out with Otira Caldwell.

Tour included:

Kitchen; LPAs toured the kitchen and observed food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the approved capacity. The refrigerator and stove are in working order. Sharps are stored in in a locked closet in the hallway, available only to authorized individuals. Trash cans has tight-fitting lid. Dishwasher are used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 38 degrees Fahrenheit and Freezer was measures at 1 degrees Fahrenheit.

Dining and Livingroom; LPAs toured the dinning and Livingroom area. LPAs observed area to be clean and furnitures in good condition. Temperature was 76 degrees Fahrenheit.

Hallway; LPAs toured the hallway and observed hallway to be clean with no pathway obstruction. LPAs inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPAs observed additional linens and hygiene items.

Medications: LPAs observed medications to be labeled and stored in separate bins inside of a locked closet in the hallway and are distributed according to physician orders. The first aid kit was complete.

Bathroom; LPAs toured the two hallway bathrooms and observed bathrooms to be clean and equipped with grab bar. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 110 degrees Fahrenheit.

Continue on LIC809-C

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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
RIVERSIDE, CA 92507

FACILITY NAME: PERRY'S RESIDENTIAL FACILITY, INC	FACILITY NUMBER: 331800240
	VISIT DATE: 04/25/2023

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Continued from LIC809

Bedroom; LPAs toured four #4 out of #4 residents bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility. Resident #4 bedroom has a private bathroom. LPAs observed bathroom to be clean and hot water was measured at 110 degrees Fahrenheit.

Garage; LPAs tour the garage and observed garage to be clean and not cluttered. Cleaning solutions are adequately secured in a locked cabinet in the garage inaccessible to clients.

Laundry; LPAs toured the laundry room and observed room to be clean. The washing machine and dryer are all in good repair and sufficient for the approved census.

Backyard; LPAs toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gate remain unlocked. There was a gazebo to provide shade over the outside table and chairs. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Three #3 staff and two #2 residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expires on 01/15/2024.

Interview; Two #2 staff and two #2 residents present were interviewed.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed with and provided to Otira Caldwell.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

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