331880549-6-17-2023-18-AS-JROO-CSVR4U-20230617124205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880549
Report Date: 06/17/2023
Date Signed: 06/17/2023 12:42:10 PM

Document Has Been Signed on 06/17/2023 12:42 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	EXCEL ASSISTED LIVING LLC		FACILITY NUMBER:	331880549
ADMINISTRATOR:	ANGELES, PAOLO		FACILITY TYPE:	740
ADDRESS:	24077 GRAFTON AVE		TELEPHONE:	(951) 239-0716
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY:	6	CENSUS: 5	DATE:	06/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Caregiver Christine Telo		TIME 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	Licensing Program Analyst (LPA) Janette Romero conducted an unannounced annual required visit to the facility at 11:25 a.m. LPA me with Administrator Paolo Angeles who was informed of the purpose of the visit. During the visit, there were five (5) residents, and two (2) staff present. The facility is made up of a one-story home with five (5) resident bedrooms, two (2) bathrooms, family room, dining area, kitchen, and an attached garage. LPA conducted a tour of the interior and exterior, and reviewed facility documents. LPA observed the following: Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage, lighting, and an operable smoke alarm/carbon monoxide detector, in accordance with Title 22 regulations. Bathrooms: Both bathrooms have a working toilet, wash basin, and were equipped with a grab bar and non-slips mats in the shower. LPA tested water temperatures in resident bathrooms and water temperatures were measured at 106- and 109-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for each resident. Kitchen: LPA observed a sufficient supply of dishes, glasses, utensils, pots, and pans. Sample menu is posted on kitchen wall. The stove is operational and refrigerator and freezer were in working condition. LPA observed sufficient perishable and non-perishable food available for the residents. Laundry: Laundry room was equipped with operable washer and dryer. A fire extinguisher was charged and mounted on laundry room wall. Centrally Stored Medications: LPA observed a first aid kit with required components, and locked area for medication storage.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EXCEL ASSISTED LIVING LLC	FACILITY NUMBER: 331880549
	VISIT DATE: 06/17/2023

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

Living/Family room: The family room had a working television and board games available for the residents. Let-Us-No poster, Long- Term Care Ombudsman poster, emergency phone numbers, and facility sketch were posted in the kitchen/family room area.

Yard/Outside Area: Covered patio seating is available for residents. A brick wall secured the backyard. All outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

There were no deficiencies noted at the time of the visit. An exit interview was conducted, and a copy of this report was reviewed and provided to facility Administrator, Paolo Angeles.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2