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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880614
Report Date: 04/19/2024
Date Signed: 04/19/2024 02:19:13 PM


Document Has Been Signed on 04/19/2024 02:19 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:LEWIS BAILEY SENIOR HOME CAREFACILITY NUMBER:
331880614
ADMINISTRATOR:LEWIS, TARIFACILITY TYPE:
740
ADDRESS:26364 MALLORY CTTELEPHONE:
(951) 430-1921
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY:6CENSUS: 3DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensees, Tari and Nikkita LewisTIME COMPLETED:
02:30 PM
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On 4/19/2024, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to conduct an annual required inspection. LPA was greeted and granted entry by Licensee, Tari Lewis who was informed of the purpose of the visit. During today's visit, there was three (3) residents and two (2) staff present.

The facility has a fire clearance for six (6) non-ambulatory residents ages 60 and above. The facility also has a hospice waiver for four (4) residents and LPA was informed three (3) residents are receiving hospice services at the facility. LPA toured the facility's interior and exterior with Licensee, Nikkita Lewis. LPA observed the facility is made up of a one-story home with three (3) resident bedrooms, one (1) bathroom, a kitchen, living room, dining room, and attached garage. Indoor and outdoor passageways are free of obstruction. LPA observed the facility has more than a 2-day supply of perishable foods and 7-day supply of non-perishable foods. LPA observed emergency food and water stored at the facility. Licensee Nikkita tested one of the smoke alarms/carbon monoxide detectors and LPA found it to be operational. LPA observed charged fire extinguishers throughout the facility. Medication is secured in a medication cart stored in the living room. Disinfectants, cleaning solutions, and detergents are secured in the locked laundry room. LPA reviewed all resident and Licensees' files. Resident files reviewed have signed and updated physician reports and admission agreements. Licensees have a valid first aid certification and administrator certificates. Residents rights, complaint procedures, Long Term Care Ombudsman information, and facility sketches are posted near the facility's front entrance. The facility does not safeguard the residents' cash resources.

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 to both Licensees.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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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