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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880905
Report Date: 06/05/2024
Date Signed: 06/05/2024 11:15:01 AM


Document Has Been Signed on 06/05/2024 11:15 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:TEMECULA MEMORY CAREFACILITY NUMBER:
331880905
ADMINISTRATOR:GEDDIE, JAMESFACILITY TYPE:
740
ADDRESS:44320 CAMPANULA WAYTELEPHONE:
(951) 428-4990
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:64CENSUS: 2DATE:
06/05/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Azizi Baranauskas, Clinical Care CoordinatorTIME COMPLETED:
11:30 AM
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On 6/5/24 Licensing Program Analyst (LPA) Javina George made an unannounced case management-health checks visit. LPA met with Azizi Baranauskas, Clinical Care Coordinator and explained the purpose of the visit. The department was notified of the facility's intent to close with the expected closure date of 6/30/24.

LPA confirmed that the facility has operable utilities (gas, electric, water) and an adequate food supply. The food (3 meals, 2 snacks) are prepared in the skilled nursing building's kitchen and is via delivery cart. There is sufficient supply of paper and hygiene supplies for the residents in care.

The facility was observed to have adequate staffing as there is one (1) Licensed Vocational Nurse (LVN) and 1 Caregiver scheduled for each AM, PM and NOC shift. There is a total of two (2) residents in care, that are expected to relocate by 6/15/24.

There were no health and safety concerns observed during today's visit.

An exit interview was conducted and a copy of this report was provided, to Azizi Baranauskas, Clinical Care Coordinator.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024
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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