<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881004
Report Date: 02/21/2024
Date Signed: 02/21/2024 03:32:58 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/21/2024 03:32 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: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:
02/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator - Lisa HendersonTIME COMPLETED:
03:42 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sara Martinez conducted a required one (1) year annual inspection visit. LPA was granted entry and met with Administrator, Lisa Henderson, who was informed of the purpose of the visit. The facility does not have residents in care. The facility is currently under renovation. Licensee has chosen to maintain the license for the facility and plans on placing residents in the facility once renovations are complete.

The facility has three separate buildings. Building "A" and building "B" are designated for residents in assisted living. Building "C" will be the administration building with a kitchen and main centralized medication room. LPA toured the interior and exterior area of the facility. The following was observed, reviewed, and inspected:



Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were in good repair and were present. Resident bedrooms had the required bedding and furniture, sufficient storage space, and lighting. LPA observed call light systems in the bedrooms. Each bedroom has a bathroom attached for residents. LPA observed bathroom appliances were operating in safe and sanitary conditions and were equipped with non-skid mats and grab bars. Facility kitchen had the ability to prepare food in a clean environment and possessed equipment and walk-in refrigerator and freezer in good working condition. LPA inspected storage areas where storage, cleaning supplies, and toxins would be locked and inaccessible to residents.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MIDTOWN VILLA
FACILITY NUMBER: 331881004
VISIT DATE: 02/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Administrator confirmed that fire alarms, fire extinguishers, and carbon monoxide detectors were serviced by the fire department. The facility has several large activity areas and dining area for residents. Building "A" and building "B" each have their own kitchenette and medication room.

Based on LPA's observation, the facility is not ready for resident placement due to currently being under renovation. Although there are no resident currently residing in the facility, renovations for the facility must be completed and in in compliance with Title 22 regulations prior to accepting residents. In addition, LPA advised the administrator that the facility must call the Community Care Licensing prior to accepting residents.

An exit interview was conducted where a copy of this report was provided to Administrator, Lisa.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2