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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881004
Report Date: 02/20/2025
Date Signed: 02/21/2025 08:36:03 AM

Document Has Been Signed on 02/21/2025 08:36 AM - 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/
DIRECTOR:		AGBISIT, MICHAELFACILITY TYPE:
740
ADDRESS:2789 RAFFERTY RD.TELEPHONE:
(951) 566-6610
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 102CENSUS: 7DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator-Kay HylandTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 02/20/25 Licensing Program Analyst (LPA) Debbie Palacios conducted a required one (1) year annual inspection visit. LPA was granted entry and met with Administrator, Kay Hyland and Maintenance Director Rick Jackson, who were informed of the purpose of the visit. The facility had 7 residents present at the time of the visit.

The facility has three separate buildings. Building "A" is designated for residents in assisting living; Building "B" is designated for the Administrative offices. Building "C" has the kitchen and main centralized medication room. LPA toured the interior and exterior area of the facility.



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 are locked and inaccessible to residents.

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 where residents are able to watch television and be part of their daily activities.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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: MIDTOWN VILLA
FACILITY NUMBER: 331881004
VISIT DATE: 02/20/2025
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LPA reviewed the Medication Administration Record along with the physical medications for six (6) residents and did not discover any discrepancies. LPA reviewed six (6) resident files and observed residents had updated admission agreements. Staff files reviewed had the Department's required training records and valid first aid/CPR certification. Exit signs, emergency contact information, client's personal rights, and complaint information are visibly posted throughout the facility.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted, and a copy of this report was reviewed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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