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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880938
Report Date: 07/07/2020
Date Signed: 07/08/2020 11:03:15 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:RM CARE HOMEFACILITY NUMBER:
331880938
ADMINISTRATOR:CLAVERIA,MARIA AURORA FAYEFACILITY TYPE:
740
ADDRESS:35397 SAGUARO DRIVETELEPHONE:
(951) 467-0240
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:6CENSUS: 0DATE:
07/07/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Maria Aurora Faye ClaveriaTIME COMPLETED:
03:15 PM
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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 Maria Cleveria. Currently there are 0 residents in care.

The home is a four (4) bedroom, two (2) full baths home with a living room, dining room and kitchen. Per the approved fire clearance, the licensee is approved for six (6) 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 116 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 outside cabinet in the hallway. Staff and resident files will be locked in a file cabinet in the office. The medications will be locked in medicine cabinet located in the office area. A complete first aid kit was observed and to be complete. The chemicals will be locked and kept in the cabinet in the garage. The backyard was observed to be fully fenced with an unlocked gate and had covered patio, ceiling fan, 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. Cleveria 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: 07/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2020
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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