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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881004
Report Date: 02/17/2021
Date Signed: 02/18/2021 09:18:54 AM

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:MIDTOWN VILLAFACILITY NUMBER:
331881004
ADMINISTRATOR:AGBISIT, MICHAELFACILITY TYPE:
740
ADDRESS:2789 RAFFERTY RD.TELEPHONE:
(951) 566-6610
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY:102CENSUS: 0DATE:
02/17/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Michael Agbisit & Elizabeth OdunjoTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Stephanie Williams conducted a pre-licensing inspection via video-conferencing application due to the COVID-19 pandemic. LPA identified herself and conducted the tele-visit with Licensee's Representative, Michael Agbisit and Administrator, Elizabeth Odunjo.

The pending application is for a Residential Care Facility for the Elderly. The facility has been granted a fire clearance for 80 non-ambulatory and 22 bedridden residents by the Hemet Fire Department on 12/2/2020. The facility has three separate buildings, of which, two buildings are designated for residents in assisted living and memory care. LPA toured the interior and exterior area of the facility. The following was observed, reviewed, and inspected:

LPA inspected a sample of resident bedrooms; bedrooms have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, and lighting. LPA observed call light systems in the bedrooms. LPA inspected a sample of resident bathrooms; bathroom appliances were operating in safe and sanitary conditions and were equipped with non-skid mats and grab bars. LPA inspected the kitchen and found it to be clean with sufficient food storage space. LPA inspected storage areas; dangerous objects, cleaning supplies, and toxins were locked and inaccessible to residents. Administrator confirmed that fire alarms, fire extinguishers, and carbon monoxide detectors were serviced prior to fire clearance inspection. LPA inspected the common areas; there were several large activity areas and a dining area for residents. LPA observed required postings including the department's complaint poster, residents personal rights, and the facility's emergency/disaster plan. The facility was equipped with a complete first aid kit as well as the first aid manual. There was a locked and centralized storage area for medications. The facility had a designated area for client files and staff files. The facility had a working telephone for resident use. LPA also observed activities for the residents; such as, board games and a pool table. LPA inspected the outdoor space; there was one fountain on the property, which LPA recommended that it should be filled with rocks or surrounded/covered with chain link fence. In the backyard area, there was a shaded seating area for
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
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: MIDTOWN VILLA
FACILITY NUMBER: 331881004
VISIT DATE: 02/17/2021
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residents. All buildings appear to be in good repair and are equipped with functioning utilities. Overall, the facility appears to be operable for residents in conditions that are clean and safe.

Pre-Licensing is complete and this facility has no deficiencies. LPA completed the Component III presentation with Administrator at the conclusion of the inspection. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy was provided to Agbisit & Odunjo via email.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
LIC809 (FAS) - (06/04)
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