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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880905
Report Date: 09/11/2024
Date Signed: 09/11/2024 09:36:07 AM


Document Has Been Signed on 09/11/2024 09:36 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: 0DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Azizi Baranauskas - Clinical Care CoordinatorTIME COMPLETED:
09:45 AM
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On 09/11/24 at 8:39am Licensing Program Analyst (LPA) Javina George made an unannounced visit to conduct a 1 year required visit/annual inspection. LPA met with Azizi Baranauskas, Clinical Care Coordinator and explained the purpose of the visit. At the time of the visit there was (1) staff and (0) residents in care.

The facility is currently in the process of closing and does not have any residents in care. The last resident discharged from the facility on 06/15/24. There were not any medications, staff and resident files available to review as there are not any staff actively working at this time.

The signal system and smoke and carbon monoxide detectors were observed to be operable. LPA did not observe the food supply as there are not any residents in care. The facility has personal protective equipment and an approved infection control plan on file. The postings were observed to be still be hanging throughout the facility.

The facility was observed to be clean, clutter and odor free. The passageways are free from any obstructions. There are no known guns, ammunition, as well as pools or bodies of water on the premises. Based on today's inspection no deficiencies were cited in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

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: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
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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