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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881014
Report Date: 03/15/2021
Date Signed: 03/15/2021 12:32:06 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:SIERRA RESIDENTIAL CAREFACILITY NUMBER:
331881014
ADMINISTRATOR:GOFFUR, EFAZFACILITY TYPE:
740
ADDRESS:37182 SIERRA GROVE DRIVETELEPHONE:
(951) 742-1742
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 0DATE:
03/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Efraz GoffurTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Javier Prieto conducted an announced visit with facility administrator for the purpose for performing a virtual pre-licensing inspection. LPA Prieto met with administrator Efraz Goffur. Fire clearance is approved for six (6) non-ambulatory, of which six (6) can be bedridden, on 11/04/2021. Facility will serve Elderly, age 60 years and above.

Structure: Facility is a six (6) bedroom one story house with two car garage. The facility maintains ample area for al clients at all times. The client bedrooms can accommodate the client's furnishings.
Bathrooms: All bathrooms have a working toilet, shower and sink. Bathrooms have appropriate washing supplies and towels for client use.
Linens: Will be kept in the hallway adjacent to all the bedrooms.
Hygiene Supplies: Will be kept locked in the cabinet in the home and in the garage area.
Food Service: Kitchen has adequate counter and cupboard space to meet the staff and client’s needs. Stove burners, oven, microwave, washer & dryer are working. Knives are kept locked in the pantry located in the kitchen. Refrigerator is in working order.
Smoke detectors and Carbon Monoxide Units Were tested and found in working condition.
Toxics Will be stored in a locked in the laundry room, locked closets as well garage.
Medications Will be kept centrally stored and locked in the kitchen cabinet including the first aid kit will be kept in cabinet. Medication Administrator Records logs will be locked and possible use of e-MAR (electronic format.
Resident & Staff Files; Will be centrally stored and locked in the closet in the kitchen area.
Overall, the residence meets Title 22 requirements for licensing standards. No corrections are needed at this time. A copy of this report was provided to the administrator. On this day a Component III orientation was conducted with administrator Efraz Goffur.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021
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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