331880711-8-29-2023-18-AS-JSRS-CV6UWV-20230829155721

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880711
Report Date: 08/29/2023
Date Signed: 08/29/2023 03:57:26 PM

Document Has Been Signed on 08/29/2023 03:57 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	AVALON RANCH RESIDENTIAL FACILITY		FACILITY NUMBER:	331880711
ADMINISTRATOR:	WALKER, DANA		FACILITY TYPE:	735
ADDRESS:	1521 AVILA DRIVE		TELEPHONE:	(951) 796-7623
CITY:	PERRIS	STATE: CA	ZIP CODE:	92571
CAPACITY: 4		CENSUS: 4	DATE:	08/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Dana Walker, Licensee		TIME COMPLETED:	04:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived at the facility to conduct an unannounced annual inspection. LPA was greeted outside the front of the home by Dana Walker, Licensee and explained the purpose of the visit. A tour of the home was conducted inside and out. LPA conducted staff and resident interviews. At the time of the visit, three (3) residents and two (2) staff were present. During the visit both the inside and outside were inspected and the following was observed. The home is a five bedroom, three and a half bath, two story home with a front living room, family room, dining room and kitchen. Per the fire clearance the home is approved for four ambulatory residents. The bedrooms are furnished with a bed, dresser, night stand, light and a chair for residents use. The facility has an ample supply of towels, linens, and hygiene supplies. The water was tested and measured above 120 degrees, Licensee adjusted the temperature, will continue to monitor and adjust accordingly . The smoke and carbon monoxide detectors were tested and are in working order. One fully charged fire extinguisher was observed in the kitchen and one upstairs. The kitchen is fully stocked with dishes, silverware, pots and pans. LPA observed a seven day supply of non-perishable and two day supply of perishable food for residents. The medications and knives are kept locked and stored in the downstairs office, in a file cabinet. The chemicals are locked and stored in the downstairs hall closet. A complete first aid kit was observed. The client and staff files are also locked in the downstairs office in a file cabinet and in the garage. The backyard was observed to be fully fenced with unlocked gates and has shade and seating for residents. LPA observed medications and medication logs. Medications appear to be dispensed appropriately according to physicians orders. LPA reviewed resident files. Resident files contained appropriate required documents such as current IPP, Service Agreement and Physicians reports. LPA reviewed P&I logs, records are balanced. P&I funds are kept separately from facility funds.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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: AVALON RANCH RESIDENTIAL FACILITY	FACILITY NUMBER: 331880711
	VISIT DATE: 08/29/2023

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Staff files were reviewed and contained background criminal clearance, current CPR/first aid certification and current training.

Facility is conducting drills on a regular basis. The last drill conducted was on 7/11/2023
No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted and a copy of this report was provided to Licensee, Dana Walker.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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