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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880750
Report Date: 08/24/2021
Date Signed: 08/24/2021 03:55:33 PM

Document Has Been Signed on 08/24/2021 03:55 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 SERVANT'S HEART ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
331880750
ADMINISTRATOR:NELSON, SHAWNTAEFACILITY TYPE:
735
ADDRESS:25703 CEDAR RIVER COURTTELEPHONE:
(951) 672-2270
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY: 4CENSUS: 3DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Tanesha Curtis, Facility ManagerTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Deborah Mullen conducted an unannounced annual inspection. LPA met with Tanesha Curtis, Facility Manager. LPA conducted a walk through inspection of the home and observed the home to be a four bedroom, two bath home with a staff office, living room and dining room/kitchen.

LPA observed the bedrooms to have a bed, dresser, night stand and appropriate lighting. The bathrooms were observed to be clean, safe and sanitary for residents use. The facility was observed to meet the minimum requirement of seven days non-perishable and two days perishable food supply. The medications are locked and stored in a kitchen cabinet. Chemicals and cleansers are locked and inaccessible to residents. The backyard was observed to have seating and shade area for residents comfort and to be free of items that would pose a hazard to residents.

During the inspection LPA reviewed infection control practices and procedures with the Facility Manager. Based on the discussion it appears the facility is following current infection control guidelines.

The facility appears to be in compliance with Title 22 regulations. No deficiencies were observed or cited. An exit interview was conducted and a copy of this report was reviewed with and provided to Ms. Curtis.


SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Deborah Mullen
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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