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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880693
Report Date: 06/17/2024
Date Signed: 06/17/2024 02:54:46 PM


Document Has Been Signed on 06/17/2024 02:54 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:ST FRANCIS VILLAFACILITY NUMBER:
331880693
ADMINISTRATOR:DANG, ANHTUANFACILITY TYPE:
740
ADDRESS:23571 RHEA DRTELEPHONE:
(714) 306-3259
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:6CENSUS: 1DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee, Antuan DangTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit for the required annual. LPA met with Licensee, Antuan Dang who was informed of the purpose of the visit. LPA was informed by licensee that client would be retuning from their day program and would be attending an appointment at 3:00pm.

LPA conducted a walk through of the home. LPA observed the physical plant. LPA observed the client and staff room. No firearms or pool is being kept at the facility. LPA observed the locked medication, sharps and cleaning supplies were locked and inaccessible to clients. LPA check the food supply which met the department requirements. LPA observed the outdoor space was free of hazards.
LPA checked the emergency supply and first aide kit. LPA reviewed the facilities last fire drill April 16, 2024 was conducted on and reviewed emergency and disaster plan.

No health and safety issues were noted at the time of the visit. Due to time constraints LPA will return on another date to complete the inspection. No deficiencies were cited at the time of the visit. An exit interview was conducted and this report was reviewed and provided.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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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