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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881007
Report Date: 02/26/2024
Date Signed: 02/26/2024 11:19:35 AM


Document Has Been Signed on 02/26/2024 11:19 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:PURE HOPE CAREFACILITY NUMBER:
331881007
ADMINISTRATOR:FADDOUL, LEVIFACILITY TYPE:
740
ADDRESS:78740 SANITA DRIVETELEPHONE:
(760) 834-8242
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:6CENSUS: 5DATE:
02/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Caregiver, Milagro Perez TIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that five (5) clients live at this facility and home at the time of the inspection. There was two (2) staff members present. The Administrator, Levi Faddoul spoke to the LPA on the phone. The caregiver, Milagro Perez conduct and completed the facility tour.

Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Levi C. Faddoul Administrator’s certificate expiration date is 06/06/2024.



Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PURE HOPE CARE
FACILITY NUMBER: 331881007
VISIT DATE: 02/26/2024
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Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 74 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 107 degrees F. Laundry is done in the designated laundry area in the garage. The garage door is locked, where there is storage for laundry soap and other cleaning chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There is one (1) secured fireplace at this facility. There are zero (0) pool at the facility. There are two (2) gates that have a self-latching lock on the northwest and northeast of the house. LPA observed one (1) emergency supplies and first aid with the required components.

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.

Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed if they were dispensed accurately.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed six (6) dual smoke detectors and carbon monoxide detectors. There was one (1) fire extinguisher on site, last checked and charged on 01/19/2023.
Pursuant to the Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to the Caregiver, Milagro Perez.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024
LIC809 (FAS) - (06/04)
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