<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800454
Report Date: 11/27/2023
Date Signed: 11/27/2023 12:56:22 PM

Document Has Been Signed on 11/27/2023 12:56 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:FAITHWORKS RESIDENTIAL HOMESFACILITY NUMBER:
331800454
ADMINISTRATOR:GROVE, ZENOBIAFACILITY TYPE:
735
ADDRESS:31922 BAY LAUREL STREETTELEPHONE:
(951) 430-1429
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 4CENSUS: 4DATE:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mary Smith, House ManagerTIME COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/27/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Caregiver, Danielle Mitchell who was informed of the purpose of visit. LPA also met House Manager, Mary Smith. At the time of visit there was 4 staff and 2 residents present. LPA was informed one resident is at the Day Program and one resident went home to family house. LPA toured the facility inside and out with Mary Smith.

Tour included:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the census. The refrigerator and stove are in working order. Sharps are stored in a locked box under the kitchen sink, available only to authorized individuals. Trash cans has tight-fitting lids. Fridge, freezer, and all need appliances were present and shown to be in working condition and clean.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 68 degrees Fahrenheit.



Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA 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. LPA observed additional linens and hygiene items.

Medication: Medications were labeled and stored in separate bins inside of a locked medication cabinet and are distributed according to physician orders. The first aid kit was complete.



Continue on LIC809-C.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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: FAITHWORKS RESIDENTIAL HOMES
FACILITY NUMBER: 331800454
VISIT DATE: 11/27/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809.

Bathroom: LPA toured two hall way bathrooms and observed bathrooms to be clean and equipped with grab bar and non-skid mat. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 114 degrees Fahrenheit.

Bedroom: LPA toured four #4 out of #4 resident’s bedrooms 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 #1 bedroom has a private bathroom. LPA observed bathroom to be clean and hot water was measured at 114 degrees Fahrenheit.

Garage: LPA tour the garage and observed garage to be clean. Cleaning supplies are stored away in the garage inaccessible to clients.

Laundry: Washing machine and dryer are all in good repair and sufficient for census.

Backyard: LPA 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. 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. Fridge and freezer are large enough to accommodate required perishable foods.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Three #3 staff and #3 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 8/7/2025.

Interview: Three #3 staff and two #2 resident were interviewed.

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

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2