331880980-10-17-2023-18-AS-CNWE-CWPTY6-20231017150813

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880980
Report Date: 10/17/2023
Date Signed: 10/17/2023 03:08:17 PM

Document Has Been Signed on 10/17/2023 03:08 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MAMA ANGELINA COCONOCHO		FACILITY NUMBER:	331880980
ADMINISTRATOR:	GONZALEZ, MARIA ROSARIO		FACILITY TYPE:	740
ADDRESS:	862 PIKE DRIVE		TELEPHONE:	(951) 335-1239
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	6	CENSUS: 5	DATE:	10/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Maria Gonzalez, Licensee		TIME COMPLETED:	03:15 PM

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On 10/17/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Licensee, Maria Gonzalez who was informed of the purpose of the visit. At the time of visit there was 1 staff and 5 residents present. LPA toured the facility inside and out with Maria Gonzalez.

Tour included:

Kitchen; LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the census. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen cabinet, available only to authorized individuals. Trash cans has tight-fitting lids. Dishwasher is used to clean and sanitize dishes. Fridge, Freezer, and all need appliances were present and shown to be in working condition and clean.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 77 degrees Fahrenheit.

Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medication; LPA observed medications were labeled and stored in separate bins inside of a locked kitchen cabinet and are distributed according to physician orders. The first aid kit was complete.

Continue on LIC809-C

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MAMA ANGELINA COCONOCHO	FACILITY NUMBER: 331880980
	VISIT DATE: 10/17/2023

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Continued from LIC809.

Bathroom; LPA toured two #2 out of #2 resident’s bathrooms and observed bathrooms to be clean and equipped with grab bar. There is also a good number of personal toiletries available for the residents in care.

Bedroom; LPA toured four #4 out of #4 residents bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility.

Garage; LPA tour the garage and observed garage to be clean and not cluttered.

Laundry; Laundry supplies are stored away in the garage, inaccessible to clients, washing machine and dryer are all in good repair and sufficient for the census.

Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents. Fridge and Freezer is large enough to accommodate required perishable food.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Three #3 staff and #3 residents' records were reviewed. All required postings were posted near the entryway and throughout the facility. The administrator certificate expires on 9/26/2024.

Interview; one #1 staff and three #3 residents were interviewed.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Maria Gonzalez.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

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