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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800464
Report Date: 04/03/2024
Date Signed: 04/03/2024 02:25:53 PM


Document Has Been Signed on 04/03/2024 02:25 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:MASHBURN HOMES INCFACILITY NUMBER:
331800464
ADMINISTRATOR:MARIAN BUNDALIANFACILITY TYPE:
740
ADDRESS:853 PIKE DRTELEPHONE:
(951) 927-0611
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:5CENSUS: 4DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Marian Bundalian, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPA met with Administrator, Christopher bundalian, and informed him of the purpose for the visit.

PHYSICAL PLANT: Residents 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 the Administrator, there are no weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to residents 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 residents. The 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 residents 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 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.

RECORD REVIEW: Staff files had required training, including, but not limited to, Activities of Daily Living (ADL) training, Medication training, first aid training, and Restricted Health Condition training. Staff present have the required criminal record clearances. An Individual Program Plan (IPP) and Medical Assessment (Physician's Report) was on file for client in care.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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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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: MASHBURN HOMES INC
FACILITY NUMBER: 331800464
VISIT DATE: 04/03/2024
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Administrator Bundalian has an active Administrator's certificate, which expires on 08/11/2025.

MEDICATION: Medication was reviewed for 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.

This report was reviewed with Administrator Bundalian and a copy was provided. No deficiencies were cited at time of inspection.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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