331880889-5-23-2024-18-AS-KBAG-D5JNQT-20240523104027

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880889
Report Date: 05/23/2024
Date Signed: 05/23/2024 10:40:42 AM

Document Has Been Signed on 05/23/2024 10:40 AM - 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:	ELDERLY BETTER HOME		FACILITY NUMBER:	331880889
ADMINISTRATOR:	ALSAYEH, HALA		FACILITY TYPE:	740
ADDRESS:	20461 MYRON ST		TELEPHONE:	(951) 349-3440
CITY:	PERRIS	STATE: CA	ZIP CODE:	92570
CAPACITY:	4	CENSUS: 0	DATE:	05/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Administrator, Hala Alsayeh		TIME COMPLETED:	11:00 AM

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	Licensing Program Analyst (LPA) Kathleen Banrasavong attempted to conduct an annual inspection at the facility on 05/20/24 at 1:00PM. LPA knocked on the door and rang the doorbell. There was no answer at the facility. LPA contacted the Licensee and Administrator and left a message informing them of the purpose of the visit. A business card was left at the door. LPA left at 01:40PM. Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection on 05/23/2024. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that zero (0) clients live at this facility. There was one (1) staff members present. The Administrator, Hala Alsayeh conducted and completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA would have reviewed for client records. Zero (0) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024

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 3

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: ELDERLY BETTER HOME	FACILITY NUMBER: 331880889
	VISIT DATE: 05/23/2024

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
26
27
28
29
30
31
32

Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a location for sharps in the kitchen.

Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 74 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 107.0 degrees F. Laundry is done in the laundry room. There is a locked closet for storing laundry soap, cleaning supplies and chemicals in the closet located in garage. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There are zero (0) fireplaces at this facility. There is not a pool at the facility. There are three (3) secured gates that have a self-latching lock on the northwest, northeast and front of the house. LPA observed emergency supplies and one (1) first aid kits. The last emergency fire drill was conducted on 04/01/2024.

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: ELDERLY BETTER HOME	FACILITY NUMBER: 331880889
	VISIT DATE: 05/23/2024

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
26
27
28
29
30
31
32

Medications/Health Related Services/Incidental Medical Services: The medications would have been centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs would be maintained separately. LPA would have reviewed medication logs and observed that they were dispensed accurately.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed six (6) smoke detectors and one (1) carbon monoxide detectors throughout the facility. There were one (1) fire extinguishers on site, date bought was 04/01/2024.

Pursuant to Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to Administrator, Hala Alsayeh.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3