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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880817
Report Date: 03/07/2024
Date Signed: 03/07/2024 12:52:02 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/07/2024 12:52 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: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:
03/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Licensee, Lidia PinaTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Licensee, Lidia Pina who was informed of the purpose of the visit. Facility currently has no clients in care.

The facility is a one story home with (5) bedrooms and (4) full bathrooms and (2) half bathrooms with attached garage. The facility does have not a pool or fire arms. LPA observed the following:

Infection Control: LPA observed hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The carbon monoxide detector was tested and operational during the visit.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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 2
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: LIDNA'S PLACE
FACILITY NUMBER: 331880817
VISIT DATE: 03/07/2024
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Record Review and Resident/Staff Files: LPA reviewed staff files and training along with CPR/First Aid. There are no clients and no client files.

Health Related Services/ Incidental Medical Services: LPA observed where client medications would be kept.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan and emergency disaster supplies.

No deficiencies were cited at the time of the visit. Technical Violation was issued for facility having (2) over night visitors at the time of the visit. There are no clients in care, but Licensee was informed of the need to have over night visitors fingerprinted. An exit interview was conducted where a copy of this report was reviewed and provided to, Licensee Lidia Pina.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
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