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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880836
Report Date: 06/13/2022
Date Signed: 06/13/2022 03:27:46 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/13/2022 03:27 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:ALOHA HOME CARE IIIFACILITY NUMBER:
331880836
ADMINISTRATOR:MARTINEZ, IARISH CHRISTIANFACILITY TYPE:
740
ADDRESS:39869 SOUTH CREEK CIRCLETELEPHONE:
(951) 760-2345
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 0DATE:
06/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Representative- Agnes MartinezTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA met with facility represntative Agnes Martinez, who was informed of the purpose of the visit. At the time of visit there was 2 staff and 0 residents present. The facility currently has no residents and no confirmed or suspected Covid-19 cases.

During today's visit, LPA toured the inside and outside of the facility. LPA walked through and observed the ktichen, backyard, all 5 bedrooms, and 3 bathrooms. Furniture such as a bed, desk lamp, chair, night stand were readily available. All bathrooms are fully stocked with toilet paper, soap, and paper towels. The kitchen was clean and stocked with no perishable foods cooking pans and pots, and utensils. There is a designated area for medication, sharp objects and cleaning supplies. The living room and dinning area have enough seating for the capacity of the facility which is for (6) residents. The outdoor area is clean and free of hazards and has a shaded seating area for (6) residents.

There were no deficiencies noted at the time of the visit. An exit interview was conducted, and a copy of this report was reviewed and provided to facility representative, Agnes Martinez.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
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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