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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880960
Report Date: 08/23/2023
Date Signed: 08/23/2023 04:09:56 PM

Document Has Been Signed on 08/23/2023 04:09 PM - 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:SIERRA RIDGE HOMEFACILITY NUMBER:
331880960
ADMINISTRATOR:MARCAIDA, NATALIEFACILITY TYPE:
735
ADDRESS:30167 SIERRA RIDGE WAYTELEPHONE:
(951) 926-9977
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY: 4CENSUS: 2DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Omar Talla, LicenseeTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an required 1 year visit. LPA was granted entrance by Caregiver, Jesse Arellano. Licensee Omar Talla arrived shortly thereafter. The facility is a five (5) bedroom three (3) bathroom one story home. LPA conducted staff and resident interviews. A tour of the facility was conducted inside and out.

During the tour the following was observed: Required accommodations in resident bedrooms and bathrooms. Fixtures and furniture for an operational facility are present and in good repair. All passageways were free of obstructions. Charged fire extinguishers and the fire alarm system was operable. Medications are kept centralized and locked. Hazardous items are kept inaccessible to residents. Hot water was tested at 115.7 degrees Fahrenheit. Fire Drills are conducted monthly, last fire drill was on 7/8/2023. Emergency food and other supplies are stored in the garage. Outside area is free from obstruction.

Kitchen/Food Service: LPA observed the kitchen to be clean and free of odor and all food is stored and prepared in a healthful manner. All frozen and refrigerated food is sealed correctly and protected against contamination. LPA observed an appropriate food supply of 2-day perishable and 7-day non-perishable.

Care & Supervision: Facility has sufficient care staff.

Administration: Emergency exiting plans, telephone numbers and Ombudsman information are posted.
CONTINUE ON LIC809C....
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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: SIERRA RIDGE HOME
FACILITY NUMBER: 331880960
VISIT DATE: 08/23/2023
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CONTINUED FROM LIC 809...

Record Review and Resident/Staff Files: Current staff have Criminal Clearance and CPR/1st Aid certification. Resident records were reviewed and contained required documents. P&I funds are kept in a locked box separately from facility funds.

Medication Review: LPA reviewed medication and medication log. Residents' medications are being dispensed according to physician's orders.

Based on the information received during this visit today in the areas reviewed, there are zero (0) deficiencies observed per Title 22, Division 6 of The California Code of Regulations. Exit interview conducted and a copy provided to Licensee, Omar Talla.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
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