331880789-11-13-2024-18-AS-APEZ-DAZ3HW-20241113171638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880789
Report Date: 11/13/2024
Date Signed: 11/13/2024 05:16:44 PM

Document Has Been Signed on 11/13/2024 05:16 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:	ELIZABETH MANOR RESIDENTIAL CARE II		FACILITY NUMBER:	331880789
ADMINISTRATOR/ DIRECTOR:	KNIGHT, GIZELE		FACILITY TYPE:	735
ADDRESS:	20621 GELMAN DRIVE		TELEPHONE:	(951) 421-7011
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92508
CAPACITY: 4	TOTAL ENROLLED CHILDREN: 0	CENSUS:	DATE:	11/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:55 PM
MET WITH:	Administrator Gizele Knight		TIME VISIT/ INSPECTION COMPLETED:	05:25 PM

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Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with administrator,Gizele Knight and Niicole Knight-Glass. The LPA informed the Administrator of the purpose for the visit. The inspection included the following:

LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility consists of four (4) resident bedrooms, three (3) bathrooms, a kitchen and dinning area, a living room area, a garage and laundry area, and yard with an umbrella covering with sufficient seating and space for activities. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Laundry is set up in the side hallway and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home and no bodies of water observed.

LPA began review of client records. Four (4) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, IPP, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

LPA began review of employee records- (5) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 06/05/2026 and CPR expiration of 08/22/2025.

Jazmond D Harris	TELEPHONE: (951) 529-2439
Armando Perez	TELEPHONE: (951) 248-2222
	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

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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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: ELIZABETH MANOR RESIDENTIAL CARE II	FACILITY NUMBER: 331880789
	VISIT DATE: 11/13/2024

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LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen.

Medications are centrally stored. There is a locked rolling cart allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

P&I- was reviewed. LPA observed that the facility maintains a separate log for each individuals’ monies. Money counted count was accurately reflected on the ledger.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors are a combined unit and were tested and found to be operational. Fire extinguishers was observed to be serviced and in compliance with the expiration date of, 02/10/2025. The facility is conducting emergency disaster drills monthly; last done on 10/23/2024.

Based on the information received during this visit today in the areas reviewed, there are no deficiency that are being cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Administrator, Gizele Knight and Niicole Knight-Glass.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 529-2439
LICENSING EVALUATOR NAME: Armando Perez	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC809 (FAS) - (06/04)

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