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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880585
Report Date: 06/04/2024
Date Signed: 06/04/2024 03:28:48 PM


Document Has Been Signed on 06/04/2024 03:28 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:COOL MEADOW CAREFACILITY NUMBER:
331880585
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:29787 COOL MEADOW DRTELEPHONE:
(951) 246-0214
CITY:MENIFEESTATE: CAZIP CODE:
92587
CAPACITY:6CENSUS: 4DATE:
06/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH:LEAD CAREGIVER, LIZ BACLAGANTIME COMPLETED:
03:37 PM
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On April 03, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, Sylvia Busby. The facility file review was conducted in the Regional Office and additional forms were reviewed and requested on site. The facility is licensed for six Elderly Adults and is currently operating at a capacity of four Elderly Adults.

LPA Mixson toured the facility along with the Lead Caregiver, and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single-story home located at 29787 Cool Meadow Dr. Menifee, CA. 92587.

Physical Plant: The facility phone number is (951) 246-0214 and it is operable. The LPA observed the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguisher. LPA Mixson observed required postings such as "If you See Something, Say Something" the "Personal Rights" and the Ombudsman postings. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit.

Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. The overall facility is clean, the furniture is in good condition. The facility heating system and other appliances were operable currently at the time of this visit, and there were safety lights for night.

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharps are locked.

Care & Supervision: Facility has sufficient staff, two staff on site at the time of this visit.

Records Review: The LPA reviewed resident and staff files, conducted staff interviews. Previous Community Care Licensing forms were reviewed. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit.

An exit interview was conducted, and a copy of this report was given to the Lead Caregiver, Liz Balagan.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
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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