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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880894
Report Date: 04/25/2023
Date Signed: 04/25/2023 04:22:55 PM

Document Has Been Signed on 04/25/2023 04:22 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:PLEASANT WAYS ADULT RESIDENTIALFACILITY NUMBER:
331880894
ADMINISTRATOR:WALKER, KEITHFACILITY TYPE:
735
ADDRESS:761 AMOR DR.TELEPHONE:
(951) 312-1751
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 4CENSUS: 3DATE:
04/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:FACILITY MANAGER, BRIAN WALKERTIME COMPLETED:
04:40 PM
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On April 25, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection. LPA Mixson met with facility Manager, introduced self, and stated the purpose of the visit.
LPA Mixson toured the facility, along with the Facility Manager, and inspected the inside and outside of the facility. The facility is five bedroom, single story home, with a two car garage. Currently there are 3 residents residing in the home, but are in the community on an outing. Currently only the Facility Manager is present for interview questions and the Administrator will be interviewed via the telephone. The facility has two and a half baths, a kitchen, dining room, and living room. Additionally, the facility has an activity room and a back yard.
Physical Plant: The physical plant, is in good condition, neat, and orderly. The lawns and shrubbery are well maintained. Outdoor and indoor passageways are free of obstruction on todays visit. Residents bedrooms have the required bedding and furniture; such as clean mattresses, night stands, storage space, and sufficient lighting. The bedroom temperatures were comfortable. All resident bedrooms were equipped with the required items. The Facility Manager tested the hot water temperature in the restroom, in which the bathroom sink faucet tested within the required regulation. The restrooms were equipped with non-skid surfaces and grab bars. LPA Mixson observed the kitchen and dining area. The facility had a menu posted and available for review. Kitchenware was in good condition and stored safely. Emergency food and water were observed.
Continued on the next page- LIC809-C.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PLEASANT WAYS ADULT RESIDENTIAL
FACILITY NUMBER: 331880894
VISIT DATE: 04/25/2023
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Required annual continued from LIC 809, on 04/25/2023.

LPA Mixson inspected the common areas. Smoke detectors are hard wired and were last tested on 04/11/2023. Carbon monoxide alarms, along with smoke detectors were observed, and showed a green light

The fire extinguisher was in the green and last inspected on 04/11/2023. . Fireplace has screen, is covered, and is non operable.

There is a locked and centralized storage area for medications. Medications are ordered through a pharmacy that utilizes bubble packs. The facility had a designated area for resident and staff files and it was locked.

Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There was adequate seating in the common areas and sufficient space for activities. LPA Mixson observed a monthly activity calendar.

LPA Mixson reviewed six staff files, three resident files, and conducted one interview via Telephone with the Administrator, and one interview one- on one with the Facility Manger here in the facility.

There were no regulation violations observed during todays visit.

An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to Facility Manager.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC809 (FAS) - (06/04)
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