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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881042
Report Date: 01/12/2021
Date Signed: 01/12/2021 02:29:39 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:CITY HOME SENIOR LIVINGFACILITY NUMBER:
331881042
ADMINISTRATOR:DY, KHAREN MFACILITY TYPE:
740
ADDRESS:1672 GOLDEN WAYTELEPHONE:
(714) 878-4443
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY:6CENSUS: 0DATE:
01/12/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kharen DyTIME COMPLETED:
12:00 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 Administrator, Kharen Dy.

The pending application is for a Residential Care Facility for the Elderly. The facility has been granted a fire clearance for 6 non-ambulatory residents by the City of Beaumont Fire Department on 10/29/2020. The facility has a total of 5 resident bedrooms, 3 bathrooms, a kitchen/dining area, a den, family room, laundry room, and attached garage. LPA toured the interior and exterior area of the facility. The following was observed, reviewed, and inspected:

LPA inspected resident bedrooms; bedrooms have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, and lighting. LPA inspected resident bathrooms; bathroom appliances were operating in safe and sanitary conditions and were equipped with non-skid mats and grab bars. LPA observed the hot water temperature, which measured within regulation at 114 degrees F. LPA inspected the kitchen; knives, cleaning supplies, and toxins were locked and inaccessible to residents. Dishes, glasses, and utensils were in good condition and stored in a safe manner. LPA inspected the common areas; LPA observed a charged fire extinguisher, operating smoke detectors, and carbon monoxide alarms. 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. There was adequate seating in the common areas. LPA also observed activities for the residents; such as, board games and electronic devices. LPA inspected the outdoor space; there are no bodies of water on the property and there was a shaded seating area for residents. LPA observed that side gates were unlocked and kept free of obstruction.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2021
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: CITY HOME SENIOR LIVING
FACILITY NUMBER: 331881042
VISIT DATE: 01/12/2021
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Overall, the facility appears to be operable for residents in safe conditions. The physical plant was clean and in good repair.

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 Dy via email.

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

DATE: 01/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2021
LIC809 (FAS) - (06/04)
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