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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880623
Report Date: 02/23/2024
Date Signed: 02/23/2024 03:36:02 PM


Document Has Been Signed on 02/23/2024 03:36 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:MAPLETON HOUSEFACILITY NUMBER:
331880623
ADMINISTRATOR:FORD, CLEOFACILITY TYPE:
740
ADDRESS:33860 SALVIA LNTELEPHONE:
(951) 246-8631
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 6DATE:
02/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Licensee, Cleo FordTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Licensee, Cleo Ford, who was informed of the purpose of the visit. At time of visit there were (6) clients and (4) staff present.

The facility is a two story home with licensed downstairs (5) bedrooms and (2) bathrooms with attached garage. The facility does not have a pool or fire arms are kept at the facility. The facility is a residential care facility for the elderly serving elderly ages 60 and above. LPA observed the following:

Infection Control: LPA observed hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file and staff training.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The carbon monoxide detector was tested and operational during the visit.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required food items, and provisions for modified diets.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MAPLETON HOUSE
FACILITY NUMBER: 331880623
VISIT DATE: 02/23/2024
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Record Review and Resident/Staff Files: LPA reviewed staff files and training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a hallway cabinet. LPA reviewed client medications and found that MARS and medication was accounted for and had required labeling.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted on 1/2/2024.

No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was reviewed and provided to, Licensee, Cleo Ford.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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