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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880742
Report Date: 05/08/2024
Date Signed: 05/08/2024 01:27:46 PM

Document Has Been Signed on 05/08/2024 01:27 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:A HOME 4 WAYNE, INC.FACILITY NUMBER:
331880742
ADMINISTRATOR/
DIRECTOR:		WATSON, PAMELAFACILITY TYPE:
735
ADDRESS:621 GROVESIDE DRTELEPHONE:
(951) 219-2467
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 6CENSUS: 4DATE:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Staff, James WillisTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA met with Staff, James Willis, who was informed of the purpose of the visit. At time of visit there was (1) clients and (1) staff present.

The facility is a one story home, with a total of (5) bedrooms (1) being the staff office. (3) bathrooms and (4) rooms for residents. The home has an attached garage, and no fire arms and no pool. The facility is an adult residential facility. LPA observed the following:

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

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.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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 2
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: A HOME 4 WAYNE, INC.
FACILITY NUMBER: 331880742
VISIT DATE: 05/08/2024
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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 and all client medications were accounted for in MARS list.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill March 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 Staff, James Willis.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
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