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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800240
Report Date: 04/18/2024
Date Signed: 04/18/2024 04:26:53 PM

Document Has Been Signed on 04/18/2024 04:26 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PERRY'S RESIDENTIAL FACILITY, INCFACILITY NUMBER:
331800240
ADMINISTRATOR/
DIRECTOR:		ADAMS, ANDYFACILITY TYPE:
735
ADDRESS:13141 WINDSONG ROADTELEPHONE:
(951) 455-4114
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 5CENSUS: 3DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Andy Adams, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility, accompanied by Licensing Program Manager (LPM), Rikesha Stamps, and LPA, Seo Jeon, for the purpose of conducting a required annual inspection. The LPAs and LPM were greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPAs and LPM met with Administrator, Andy Adams; he was notified of the purpose for their visit.

PHYSICAL PLANT: The Licensee is operating the facility within the conditions and limitations specified on the license. Clients appear to be protected against immediate hazards. Outdoor and indoor passageways are kept free of obstruction. No pool or body of water was observed on the property. According to staff, there are no weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to clients in care. A comfortable temperature was being maintained in the home. There was sufficient lighting in all rooms to ensure the comfort and safety of clients. Hot water was tested and observed to be within regulatory requirements. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. Additional equipment for physically handicapped clients is available. The smoke and carbon monoxide alarms were tested and found to be operable. The interior and exterior areas of the home were observed to be very clean and safe.

FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. The kitchen was observed to be clean and well organized.

RECORD REVIEW: Staff files had required training; including, but not limited to, first aid training and Direct Support Professional (DSP) training. Staff present had the required criminal record clearances. An Individual Program Plan (IPP) and Medical Assessment (Physician's Report) were on file for clients in care.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PERRY'S RESIDENTIAL FACILITY, INC
FACILITY NUMBER: 331800240
VISIT DATE: 04/18/2024
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Administrator Adams has completed his Administrator's Certificate renewal, which is pending review. An earthquake drill was completed 04/01/2024.

MEDICATION: Medications were reviewed for one client in care. All medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to clients in care. Medications and medication documentation was observed to be well organized and monitored.

The home appears to be operating well within regulatory requirements. This report was reviewed with Administrator Adams and a copy was provided. No deficiencies were cited at time of inspection.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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