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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880617
Report Date: 07/05/2024
Date Signed: 07/05/2024 02:09:13 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/05/2024 02:09 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:GOLDEN EYE RESIDENTIAL CAREFACILITY NUMBER:
331880617
ADMINISTRATOR/
DIRECTOR:
ODOM-JACKSON, BEVERLYFACILITY TYPE:
735
ADDRESS:23066 GOLDEN EYE LNTELEPHONE:
(951) 907-6092
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 0DATE:
07/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Homeowner, Kerry JacksonTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Homeowner, Kerry Jackson who was informed of the purpose of the visit. At the time of the visit there was (1) staff and (0) clients present. There are currently no clients residing in the home.

The facility is a two story home with (4) bedrooms and (3) bathrooms with attached garage. No pools or firearms are being kept at the facility. The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Physical plant, floors, windows, and doors were observed to be in good repair. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects will be kept in kitchen. Client medications will be kept in a hallway closet. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. The listed administrator has a current administrator's certificate. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit with all required items.

No deficiencies were cited at the time of the visit. An exit interview was conducted.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2024
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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