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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880986
Report Date: 01/11/2021
Date Signed: 01/11/2021 12:28:50 PM

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:HONORS WAY CARE HOMEFACILITY NUMBER:
331880986
ADMINISTRATOR:VALDEZ, DIANA DFACILITY TYPE:
740
ADDRESS:26818 HONORS WAYTELEPHONE:
(562) 338-5574
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:6CENSUS: 0DATE:
01/11/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Diana ValdezTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jennifer Semin conducted a pre-licensing inspection via Zoom. LPA met with Licensee/Administrator, Diana Valdez. The application is for a Residential Care Facility for the Elderly for six (6) non-ambulatory residents, one (1) of which may be bedridden.

A tour of the pending facility was conducted inside and out. Ms. Valdez stated she will procure and install ramps at front and back doors. Overall, the pending facility is clean and of new construction. There are no pools, bodies of water, firearms or ammunition. LPA observed the bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, showers and tubs have grab bars and non-skid mats. LPA observed food storage and preparation areas are clean and sanitary. Refrigerator and freezer temperatures are maintained at appropriate temperatures. LPA observed a seven (7) day supply of nonperishable food and a two (2) day supply of perishable food. All appliances are clean and operating properly. There is a sufficient supply of linens, towels and personal hygiene items. The first aid kit was reviewed; all items are present. Ms. Valdez will procure a first aid manual. LPA observed a minimal supply of recreation and leisure items and activities, Ms. Valdez states she plans to add a variety of recreation and leisure items based on their resident’s preferences, once admitted. The backyard is completely enclosed with functioning gate to exit to front yard. Outdoor space is suitable for resident use. Ms. Valdez stated she will procure a table, chairs and umbrella for resident use. The fire extinguishers are recently serviced and completely charged. Smoke alarms and carbon monoxide detectors are present and functional. Medications will be centrally stored and secured in a locked cabinet. Ms. Valdez stated she will install a lock on her desk cabinet for staff records. All hazardous materials such as, cleaning and disinfecting supplies, knives and other sharps are locked and inaccessible to residents. Ms. Valdez stated she will put a lock on the laundry room door. All required forms are posted in a common area.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HONORS WAY CARE HOME
FACILITY NUMBER: 331880986
VISIT DATE: 01/11/2021
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The following items are required prior to approving a license. As per discussion with LPA and Ms. Valdez these items will be corrected by 1/22/2021;
1.) ramps must be installed and secured at front and back doors.
2.) install lock on laundry room door, garage door or cabinet in garage where cleaning supplies are stored.
3.) obtain outdoor table, chairs and umbrella
4.) post theft and loss program
5.) obtain First Aid Manuel
6.) install lock to secure staff records

Ms. Valdez was reminded of the statute that requires the licensee to contact LPA at CCLD 951-473-7024 within 5 business days of admitting their first resident. This notification may be done by phone, mail or fax.
An exit interview was conducted where this report was discussed and provided to Ms. Valdez via email.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2021
LIC809 (FAS) - (06/04)
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