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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880817
Report Date: 03/17/2023
Date Signed: 03/17/2023 04:36:18 PM

Document Has Been Signed on 03/17/2023 04:36 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:LIDNA'S PLACEFACILITY NUMBER:
331880817
ADMINISTRATOR:PINA, LIDIAFACILITY TYPE:
735
ADDRESS:28413 CALLE DE REMOTELEPHONE:
(951) 201-7382
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY: 2CENSUS: 0DATE:
03/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:Administrator Lidia PinaTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Janira Arreola and Jacqueline Shaw Ross conducted an unannounced annual required visit on 3/17/2023 at 03:07 p.m. LPA was granted entry and met with Administrator Lidia Pina, who was informed of the purpose of the visit. At the time of the visit there was (1) staff and (0) clients present.

The facility is a one story home with (5) bedrooms and (6) bathrooms. The clients served are adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted staff interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms. LPA observed gloves and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures.



Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present for future clients. The outdoor area was observed to be free of hazards. Laundry room was observed to be locked and was equipment observed to be in good working condition. The sharp and dangerous objects were observed to be locked in the pantry. The facility hot water was found to be 117.1F.

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 2-day supply of perishable and 7-day supply of non-perishable foods.

Care & Supervision/Administration: Emergency exiting plans, telephone numbers and personal rights were found posted in the facility. The listed administrator showed the LPA the current classes taken to renew their certificate. LPA confirmed the administrator paid and requested for a new administrator's certificate.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LIDNA'S PLACE
FACILITY NUMBER: 331880817
VISIT DATE: 03/17/2023
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Record Review and Resident/Staff Files: There were no client files, as there were no clients at the facility. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Only (1) staff is employed at this time, which is the administrator. Their file was found to be complete.

Health Related Services/ Incidental Medical Services: No medications were found in locked medication cabinet in the facility kitchen.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The facility was only able to show the LPA page 3 OF LIC610D. LPA will document technical advisory note for administrator to send the completed LIC610D to LPA by tomorrow, 3/18/2023.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Administrator, Lidia Pina.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC809 (FAS) - (06/04)
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