331880943-7-24-2023-18-AS-JROO-CU2NU2-20230724104537

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880943
Report Date: 07/24/2023
Date Signed: 07/24/2023 10:45:41 AM

Document Has Been Signed on 07/24/2023 10:45 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ELEVATION HOME		FACILITY NUMBER:	331880943
ADMINISTRATOR:	OLOSO, IFEOLUWA VICTORIA		FACILITY TYPE:	735
ADDRESS:	4390 WILLOWGLEN WAY		TELEPHONE:	(559) 385-0423
CITY:	HEMET	STATE: CA	ZIP CODE:	92545
CAPACITY: 4		CENSUS: 3	DATE:	07/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:			TIME COMPLETED:	11:00 AM

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On 7/24/2023, at 9:30 a.m., Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Dominic Osei-Prempeh who was informed of the purpose of visit. Licensee Ifeoluwa Oloso arrived during the visit. The facility is made up of four (4) client bedrooms and two (2) bathrooms. The facility is approved for four (4) ambulatory clients and serves adults ages 18-59. During the visit, there was (2) staff present and LPA was informed clients were at day program.

LPA conducted a tour of the facility’s interior and exterior and observed the following:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. LPA observed the facility met the requirement for a 2-day supply of perishable food and 7-day of non-perishable food items. Fire extinguisher is charged and mounted on kitchen wall.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. Knives/sharps are secured in a locked dining room cabinet. Home temperature was comfortably set at 74 degrees Fahrenheit.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. Carbon monoxide & smoke detectors were tested and functioning properly.

Continued on LIC809-C..

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ELEVATION HOME	FACILITY NUMBER: 331880943
	VISIT DATE: 07/24/2023

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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a cabinet in the living room. LPA reviewed physical medications for the clients as well as Medication Administration Record, no discrepancies discovered.

Bedrooms: Client bedrooms were clean, and each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathrooms were clean, and had a working toilet, shower and wash basin. The hot water temperature measured at 108- and 110-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the clients in care.

Laundry/Garage: LPA observed laundry room and garage to be clean. Washing machine and dryer are in good repair. Cleaning solutions and chemicals are secured in locked laundry room. Emergency food supplies, water, additional linen, and extra hygiene supplies are stored in the garage.

Records: Staff present have a criminal record clearance on file and are associated to the facility. Staff training is up to date. Facility sketch, personal rights information and infection control precautions were found posted throughout the facility.

Yard/Outside Area: Covered patio seating is available for the clients. A wood wall secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

LPA did not observe any deficiencies. An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee Oloso.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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