331880819-3-10-2025-18-AS-AZEO-DEMV5A-20250310160738

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880819
Report Date: 03/10/2025
Date Signed: 03/10/2025 04:07:50 PM

Document Has Been Signed on 03/10/2025 04:07 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:	CALEB HOME		FACILITY NUMBER:	331880819
ADMINISTRATOR/ DIRECTOR:	SAMANTHA PADILLA		FACILITY TYPE:	735
ADDRESS:	49252 PLUMA VERDE PLACE		TELEPHONE:	(760) 601-7307
CITY:	COACHELLA	STATE: CA	ZIP CODE:	92236
CAPACITY: 4		CENSUS: 4	DATE:	03/10/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Shantall Flores		TIME VISIT/ INSPECTION COMPLETED:	04:15 PM

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Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection. The LPA was greeted by caregiver Shantall Flores, notified her of the purpose for the visit and was allowed to enter the facility to conduct the inspection.

Facility Overview: The facility is a two stories building with four(4) residents bedrooms, One (1) activity room, three(3) bathrooms, a dinning room, a family room, an office and a kitchen area. There is no gated pool and there are no firearms on the premises.

Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the garage and inaccessible to residents. The smoke detector and carbon monoxide detector were in good working condition. LPA observed fire extinguishers to be in compliance with the department requirements and with an expiration date of March 13, 2025. The water temperature was tested within regulations measuring at 122.0 F

Care & Supervision/Administration: Adequate staff were present to supervise residents during the visit. The administrator holds a current administrator’s certificate with expiration date of May 27, 2026 and a CPR certification with the expiration date of August, 2026

Continued 809-C......

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025

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: CALEB HOME	FACILITY NUMBER: 331880819
	VISIT DATE: 03/10/2025

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Record Review and Resident/Staff Files: LPA reviewed files for two(2) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Three (3) residents' files were reviewed and contained all required documentation. LPA observed first kit to be locked and inaccessible to the residents in care. The residents and staff files were kept in a locked cabinet in the kitchen area and inaccessible to unauthorized individuals

Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the kitchen area. LPA reviewed medications for two(2) residents, confirming that all medications were listed and accounted for.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last emergency drill conducted on 03-8-2025, which met department requirements. All facility exits were clear of obstructions.

No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Administrator Stephanie Olivas.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025

LIC809 (FAS) - (06/04)

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