331880799-9-26-2024-18-AS-JGEE-D9GV46-20240926160550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880799
Report Date: 09/26/2024
Date Signed: 09/26/2024 04:05:54 PM

Document Has Been Signed on 09/26/2024 04:05 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:	WOLF CREEK RESIDENCE		FACILITY NUMBER:	331880799
ADMINISTRATOR:	AGUINALDO,KYLA-DAWN		FACILITY TYPE:	735
ADDRESS:	45561 JAGUAR WAY		TELEPHONE:	(951) 240-7189
CITY:	TEMECULA	STATE: CA	ZIP CODE:	92592
CAPACITY:	6	CENSUS: 4	DATE:	09/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Suzette Manalasan, Administrator		TIME COMPLETED:	04:15 PM

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	On 09/26/2024 at 1:20pm, Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a required 1 year/annual inspection. LPA met with Administrator Suzette where LPA explained the purpose of today's visit. At the time of the visit there was (2) staff and (4) clients present. LPA conducted a tour of the interior and exterior areas of the facility. LPA observed the following: the facility is a two story structure consisting of 5 bedrooms, and 4 bathrooms, laundry room, dining area, kitchen, family room, backyard and garage. The facility was observed to be clean and clutter free. The kitchen was observed to be clean, and had an adequate amount of dishware available for use for clients in care. The sharps, chemicals and other hazardous times were observed to be locked and inaccessible to clients in care. The food supply was sufficient as the facility was observed to have a 2 day supply of perishable and a 7 day supply of non perishable food items. Medications were reviewed and are being given according to the physician's instructions, as evidenced by the Medication Authorization Record (MAR). LPA observed medications being administered during the visit. Staff #1 (S1) was observed to be using infection control such as hand washing before and in between administration. The hot water was tested and found to be within regulatory limits measuring at 105 degrees Fahrenheit. There was a toilet handle in the bathroom upstairs that was observed to be loose, a work order was requested at the time of LPAs visit. The facility was observed to have fully charged fire extinguishers that were last inspected on May 10,24. The facility is conducting emergency disaster drills on a monthly basis, the last earthquake drill was conducted on 08/29/24. The smoke and carbon monoxide detectors are combined as well as intertwined were tested and observed to be operable.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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: WOLF CREEK RESIDENCE	FACILITY NUMBER: 331880799
	VISIT DATE: 09/26/2024

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Records review: staff present at the facility were observed to have obtained criminal record clearance and to be associated to the facility. Staff present were observed to have current training and also possessed valid Cardio Pulmonary Resuscitation (CPR) certification training. In addition the administrator Suzette's administrator certificate expires on 10/6/24. LPA observed for Suzette to be actively completing continuing education unit (CEU) training during the visit. The facility's annual fees are current, as well as the governing body/license is active and in good standing.

Client files were reviewed and were observed to have medical assessments, Individual Program Plan (IPP) and admission's agreements. The personal and incidental (P&I) funds were reviewed and matched the amount indicated on the P&I form.

The facility is using video surveillance in the common areas. Per Administrator Suzette the cameras were recently installed. LPA discussed and requested the following documents: updated facility sketch indicating where the cameras will be, signed consents from the clients and or responsible party confirming that they have been informed that the facility will be using video surveillance, as well as an addendum to the facility's program plan stating that the facility will be using video surveillance. The requested documents are due to the department by 5pm on Monday 09/30/24.

Based on today's inspection no deficiencies were issued, and the facility was inspected in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 6).

An exit interview was conducted and a copy of this report was provided to Suzette Manalasan, Administrator.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

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