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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880750
Report Date: 06/10/2024
Date Signed: 06/10/2024 01:07:21 PM

Document Has Been Signed on 06/10/2024 01:07 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 SERVANT'S HEART ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
331880750
ADMINISTRATOR/
DIRECTOR:		NELSON, SHAWNTAEFACILITY TYPE:
735
ADDRESS:25703 CEDAR RIVER COURTTELEPHONE:
(951) 672-2270
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY: 4CENSUS: 4DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Administrator, Shawntae NelsonTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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On 6/10/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to conduct an annual required inspection. LPA was greeted and granted entry by Administrator, Shawntae Nelson who was informed of the purpose of the visit. The facility has a fire clearance for four (4) ambulatory clients and serves adults ages 18 through 59.

During the visit, LPA was informed all four (4) clients were at day program. LPA toured the facility with Administrator Nelson. During the tour, LPA observed the facility is made up of a one (1) story home with four (4) client bedrooms and two (2) bathrooms along with a kitchen, dining room, living room, laundry room, and attached garage. Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting. Bathrooms have a working toilet, wash basin and non-skid mats in the shower. The hot water temperature in the bathrooms measured at 120-degrees Fahrenheit. LPA toured the kitchen and observed the facility had a 2-day supply of perishable foods and 7-day of non-perishable food items, and food is stored in a safe and healthful manner. Chemicals and disinfectants are secured in a locked kitchen cabinet under the sink. Laundry detergent is secured in a cabinet in the locked laundry room. Medications were secured in a locked kitchen cabinet. LPA reviewed physical medications for two (2) clients as well as Medication Administration Record and did not discover any discrepancies. LPA observed additional food, water, and hygiene supplies stored in the garage. The facility has charged fire extinguishers mounted throughout the home. Administrator Nelson tested one (1) of the smoke alarm/carbon monoxide detectors and LPA observed it to be operational. There are no bodies of water on the premises. Indoor and outdoor passageways were free of obstruction. Outdoor shaded seating area is available for the clients.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Nelson.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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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