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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881077
Report Date: 03/25/2021
Date Signed: 03/26/2021 03:31:56 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:SEA BREEZE HOMES OF EASTVALE LLCFACILITY NUMBER:
331881077
ADMINISTRATOR:LONG, MARIAM BFACILITY TYPE:
740
ADDRESS:5897 SPRINGCREST STTELEPHONE:
(714) 299-9634
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 0DATE:
03/25/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mariam LongTIME 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, Mariam Long.

The pending application is for a Residential Care Facility for the Elderly. The facility has been granted a fire clearance for five non-ambulatory residents and one bedridden resident (Room #4) by the Norco Fire Department on 2/04/2021. The facility has a total of six bedrooms; of which four rooms are designated for residents and two rooms are designated for staff, three bathrooms, a kitchen/dining area, family room, laundry room, and attached garage. The physical plant appeared to be clean and in good repair. Utilities such as gas, electric, and water were functional. There were no apparent obstructions to passageways and there was no bodies of water observed on the property at the time of visit. The Administrator confirmed that fire/carbon monoxide alarms were working properly and were serviced during fire clearance inspection. LPA inspected the property and observed the following additional items:

LPA inspected resident bedrooms; the bedrooms were equipped with the required bedding and furniture, such as, mattress/box spring, sufficient storage space, and lighting. LPA inspected resident bathrooms; the bathroom appliances were operational and the showers/bathtubs were equipped with non-skid mats and grab bars. LPA inspected the kitchen; knives, cleaning supplies, and toxins were locked and inaccessible to residents and stored separate from food supply. The dishes, glasses, and utensils were in good condition and stored in a safe manner. LPA also observed a locked and centralized storage area for medications in the kitchen. LPA inspected common areas and observed required postings including the Department's complaint poster and residents' personal rights. LPA observed that the facility was equipped with a complete first aid kit as well as the first aid manual. The facility had a designated area for client files and staff files. There was adequate seating in the common areas. LPA also observed activities for the residents; such as, board games and books. LPA inspected the outdoor space; a shaded seating area for residents and unobstructed side
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
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: SEA BREEZE HOMES OF EASTVALE LLC
FACILITY NUMBER: 331881077
VISIT DATE: 03/25/2021
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gate which allowed for safe exit were observed. Overall, the facility appears to be operational for the health and safety of residents in care.

The Pre-Licensing Inspection is complete and there are no deficiencies. LPA conducted 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 Long via email.

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

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
LIC809 (FAS) - (06/04)
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