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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880913
Report Date: 07/17/2024
Date Signed: 07/17/2024 10:51:15 AM

Document Has Been Signed on 07/17/2024 10:51 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:SVS MURRIETA CCESFACILITY NUMBER:
331880913
ADMINISTRATOR/
DIRECTOR:		WHITAKER, LA RONDAFACILITY TYPE:
775
ADDRESS:39040 SKY CANYON DR SUITE 110TELEPHONE:
(626) 304-1074
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 45CENSUS: 39DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Program Director, Ana GutierrezTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Program Director, Ana Gutierrez who was informed of the purpose of the visit.

The facility is a one story building with activity rooms, staff offices, bathrooms, and kitchenette. No pools or firearms are being kept at the facility. The facility does not provide medication storage or administration, does not provide meal services, and does not have an outdoor recreation area.

Infection Control: The LPA observed the hand washing stations in the facility, hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility.



Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. No sharp and dangerous objects were observed to be out or accessible to clients. The hot water temperature 105F.

Food Service: LPA observed facility kitchenette had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility snacks, storage space and dates meet department standards.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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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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: SVS MURRIETA CCES
FACILITY NUMBER: 331880913
VISIT DATE: 07/17/2024
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Record Review and Resident/Staff Files: LPA reviewed (5) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. (5) client files were reviewed, and possessed all required paperwork.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill 6/19/2024, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit with all required items.

No deficiencies were cited at the time of the visit. An exit interview was conducted with Program Director, Ana Gutierrez.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
LIC809 (FAS) - (06/04)
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