<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880742
Report Date: 06/15/2021
Date Signed: 09/21/2021 02:32:52 PM

Document Has Been Signed on 09/21/2021 02:32 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A HOME 4 WAYNE, INC.FACILITY NUMBER:
331880742
ADMINISTRATOR:WATSON, PAMELAFACILITY TYPE:
735
ADDRESS:621 GROVESIDE DRTELEPHONE:
(951) 219-2467
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 6CENSUS: 4DATE:
06/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Patrick WatsonTIME COMPLETED:
11:30 AM
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) Javier Prieto conducted an unannounced annual inspection. LPA met with Patrick Watson, lead staff. The home is licensed for 6 ambulatory residents.

The home is a five (5) bedroom, three (3) bath home with a living room, dining room and kitchen. All bedrooms are furnished with bed, night stand, dresser and chair. Bedrooms have adequate lighting for residents’ use. The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The kitchen was observed to have dishes, silverware, pots, and pans. Staff and resident files are locked in the hall closet. The medications are locked in the hall closet as well. The chemicals are locked and kept in a separate hall closet. The backyard was observed to be fully fenced with an unlocked gate and has an umbrella with table and chairs for client’s comfort while sitting outside.

During the visit LPA discussed infection control procedures and practices with Mr. Watson. The home appeared to be in compliance and no deficiencies were observed or cited.

An exit interview was conducted and a copy of this report was reviewed with and provided to Mr. Watson
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3