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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880933
Report Date: 06/05/2020
Date Signed: 07/08/2020 11:05:31 AM

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:APPLE BLOSSOM RANCH ASSISTED LIVINGFACILITY NUMBER:
331880933
ADMINISTRATOR:REYNOLDS, JEREMYFACILITY TYPE:
740
ADDRESS:15651 CECIL AVE.TELEPHONE:
(951) 505-6058
CITY:RIVERSIDESTATE: CAZIP CODE:
92508
CAPACITY:6CENSUS: 0DATE:
06/05/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jeremy Reynolds TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Kathleen Wiggins conducted an announced pre-licensing video conference inspection to the facility due to COVID-19. LPA met with Jeremy Reynolds. Currently there are 0 residents in care.

The home is a four (4) bedroom, three (3) bath home with a living room, dining room and kitchen. Per the approved fire clearance, the licensee is approved for 5 non-ambulatory residents. All bedrooms are furnished with bed, nightstand, dresser and chair. Bedrooms have adequate lighting for residents’ use. The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The water temperature was tested and measured at 114.6 degrees Fahrenheit. The smoke and carbon monoxide alarms were tested and are in operating order. LPA observed fire doors to be properly functioning. Fire extinguishers are present in the facility and fully charged. The kitchen was observed to have dishes, silverware, pots, and pans. Knives are locked in a cabinet under the kitchen sink. Staff and resident files will be locked in a file cabinet, in the hall closet. The medications will be lock in the med cart. A complete first aid kit was observed and to be complete. The chemicals will be locked and kept locked cabinet in the garage. The backyard was observed to be fully fenced with an unlocked gate and covered patio table and chairs for client’s comfort while sitting outside.


An exit interview was conducted, and a copy of this report was reviewed and provided to Ms. Reynolds via email to obtain signature.

Receipt of report was confirmed.
SUPERVISOR'S NAME: Leslie MendivelesTELEPHONE: (951) 248-2222
LICENSING EVALUATOR NAME: Kathleen WigginsTELEPHONE: (951) 205-7142
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2020
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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