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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880556
Report Date: 02/07/2024
Date Signed: 02/07/2024 03:42:03 PM

Document Has Been Signed on 02/07/2024 03:42 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:E.X.C.E.L HOUSE, THEFACILITY NUMBER:
331880556
ADMINISTRATOR:STOKES, LATASHAFACILITY TYPE:
735
ADDRESS:24051 MARIE STREETTELEPHONE:
(626) 658-1227
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 4CENSUS: 4DATE:
02/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Support Staff, Ellen Walls TIME COMPLETED:
03:45 PM
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On 2/7/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for an annual required inspection. LPA met with Support Staff, Ellen Walls who was informed of the purpose of the visit. Administrator Latasha Stokes was contacted over the phone and informed of LPA's visit. Administrator Stokes was unavailable to meet LPA at the facility.

The facility has a fire clearance for four (4) ambulatory clients and serves adults ages 18 through 59. LPA toured the facility's interior and exterior and conducted staff and resident interviews. LPA observed the home to be extremely clean. Staff present have a criminal record clearance on file and are associated with the facility. LPA toured the kitchen and observed food is stored in a safe and healthful manner. The facility has more than a 2-day supply of perishable food and 7-day supply of non-perishable food items. LPA observed emergency food, water, and additional cleaning supplies stored in the garage. The smoke alarm/carbon monoxide detector was not tested due to Client 1's hypersensitivity. LPA observed charged fire extinguishers mounted throughout the facility. During LPA's visit, clients' medication refills were delivered to the facility and Support Staff Walls was cross-referencing the medication with each of the clients' Medication Administration Record to verify all refills were delivered.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted where a copy of this report was reviewed and provided to Support Staff Walls.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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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