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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880617
Report Date: 07/20/2023
Date Signed: 07/21/2023 08:12:42 AM

Document Has Been Signed on 07/21/2023 08:12 AM - 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:GOLDEN EYE RESIDENTIAL CAREFACILITY NUMBER:
331880617
ADMINISTRATOR:ODOM-JACKSON, BEVERLYFACILITY TYPE:
735
ADDRESS:23066 GOLDEN EYE LNTELEPHONE:
(951) 907-6092
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 0DATE:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Administrator, William JacksonTIME COMPLETED:
05:00 PM
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On 7/20/2023, at 2:45 p.m., Licensing Program Analyst (LPA) Janette Romero, made an unannounced visit to the facility to conduct a required annual inspection. During the inspection, licensee or administrator were not present at the facility. The facility is currently being used as a private residence, and there are no clients placed. The individual residing in the home was informed of the purpose of the visit and granted LPA entry. LPA communicated with Administrator William Jackson over the phone.

LPA toured the facility and observed no clients in care. Per Administrator Jackson, the home is pending vendorization through Inland Regional Center and the process is approximately 90 days from finalization. Licensee stated they want to continue with the license until clients are placed.

During this visit, LPA observed the following issues and concerns:

1. Kitchen countertop had a rotten banana peel along with a dirty paper towel and kitchen knife. Refrigerator interior had stains on the bottom. Stovetop not clean.

2. Bathroom countertop had hair clippers with hair all over the countertop as well as hair all over the toilet seat. Shower was not clean and also had hairs on the shower floor.

3. Bottle of Clorox spray next to toilet seat on the floor.

Continued on LIC809-C..
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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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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: GOLDEN EYE RESIDENTIAL CARE
FACILITY NUMBER: 331880617
VISIT DATE: 07/20/2023
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4. Facility did not meet the 2-day supply of perishable food and 7-day supply of non-perishable food requirement.

4. Aside from a bed, client bedroom furniture shall include, a chair, a night stand, a lamp or lights necessary for reading.

5. Dirty clothes observed on indoor passageways and bedroom floors.

6. Bicycle in living room area along with a broom.

7. Used tissues observed on bed.

8. Unsecured knives on kitchen countertop.

9. Staff/individuals present when clients are placed shall have a criminal background clearance or exemption.

Prior to client placement, licensee or administrator will notify Community Care Licensing to ensure concerns were corrected.

Licensee or administrator not available to sign the report. A copy of the report will be sent to administrator or licensee to sign and return.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC809 (FAS) - (06/04)
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