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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880959
Report Date: 10/05/2023
Date Signed: 10/05/2023 10:47:51 AM

Document Has Been Signed on 10/05/2023 10:47 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MOUNT MENIFEE HOMEFACILITY NUMBER:
331880959
ADMINISTRATOR:TALLA, MARIA LUISAFACILITY TYPE:
735
ADDRESS:30138 MOUNT MENIFEE STTELEPHONE:
(626) 675-7256
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY: 4CENSUS: 0DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:LEAD CAREGIVER, MARK OVIVERTIME COMPLETED:
10:58 AM
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On October 05, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection. LPA Mixson spoke with the Lead Caregiver, Mark Oliver introduced herself, and stated the purpose of the visit.

LPA Mixson toured the facility, and inspected the inside and outside of the facility, and there were no obstructions to indoor and outdoor passageways currently at the time of this visit. The facility is a single story home, located at 30138 Mount Menifee Street, Menifee, CA. 92585.

Physical Plant: The LPA observed the resident bedrooms, and they are equipped with required furniture as per Title 22. The LPA inspected the two facility bathrooms, and the hot water temperature tested within regulations. Bathrooms were clean and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required postings such as; the house rules, and the "Personal Rights" postings were posted in a common area. The cleaning supplies, and the sharps were kept locked and inaccessible for when the residents are placed. There was a designated storage space for resident/staff files for when staff and residents are in place, and there was a locked file cabinet for medication once residents are placed.

There were no Title 22, Division 6 Regulation violations observed and/or cited during todays visit.

An exit interview was conducted and a copy of this report was given to the Lead Caregiver, Mark Oliver.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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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