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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880555
Report Date: 01/15/2025
Date Signed: 01/15/2025 03:01:33 PM

Document Has Been Signed on 01/15/2025 03:01 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:JNJ RESIDENTIAL CAREFACILITY NUMBER:
331880555
ADMINISTRATOR/
DIRECTOR:		JABONERO, JANICEFACILITY TYPE:
735
ADDRESS:10137 DELCRESTA AVETELEPHONE:
(951) 200-3663
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 4DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Randy Manaloto-Lead Caregiver TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Debbie Palacios made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Lead Caregiver Randy Manaloto and Caregiver James Seno who were informed of the purpose of the visit. The facility has a fire clearance for four (4) Ambulatory only, ages 18 through 59.

LPA toured the facility and reviewed records. During the tour, LPA observed the facility is made up of a one (1) story home with four (4) client bedrooms and one (1) office bedroom, two (2) bathrooms, a living room, dining room and a laundry room. All client bedrooms had the required furniture and lighting. LPA toured the facility's exterior and observed outdoor pathways were free of obstructions. Outdoor shaded seating area is available for the clients in care. LPA observed a hallway cabinet filled with clean towels, blankets, and linen, available for the clients. LPA toured the kitchen and observed the facility has a 2-day supply of perishable foods and a 7-day supply of non-perishable foods, which are stored in a safe and healthful manner. LPA observed knives and sharp instruments are secured in a locked kitchen cabinet. Cleaning solutions and disinfectants are secured in a locked cabinet in the garage. Lead Caregiver tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed one (1) charged fire extinguisher mounted in the kitchen area. Medications are secured in a locked cabinet stored in the hallway of the facility next to the client bedrooms.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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: JNJ RESIDENTIAL CARE
FACILITY NUMBER: 331880555
VISIT DATE: 01/15/2025
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LPA reviewed the Medication Administration Record along with the physical medications for two (2) clients and did not discover any discrepancies. LPA reviewed random client files and observed clients had updated Individual Program Plans and signed admission agreements. The facility conducts the Emergency and Disaster drill on a monthly basis; facility's last disaster drill was conducted on 01/13/25. LPA reviewed the Record of Client's/Resident's Safeguarded Cash Resources (LIC 405) and Lead Caregiver Randy reviewed the physical monies for one (1) client, and no discrepancies were discovered. Exit signs, emergency contact information, client's personal rights, and complaint information are visibly posted through out the facility.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted, and a copy of this report was reviewed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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