<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881084
Report Date: 06/19/2023
Date Signed: 06/19/2023 01:28:33 PM

Document Has Been Signed on 06/19/2023 01:28 PM - 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:CLEAR HEARTSFACILITY NUMBER:
331881084
ADMINISTRATOR:ROLDAN, TIANYAFACILITY TYPE:
735
ADDRESS:327 PINNACLE STTELEPHONE:
(951) 490-4080
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 4CENSUS: 4DATE:
06/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Licensee Tianya RoldanTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Janette Romero conducted an unannounced annual required visit to the facility at 11:45 a.m. LPA was greeted and granted entry by Licensee Tianya Roldan who was informed of the purpose of the visit. Licensee has a current Administrator’s Certificate, which expires on 2/20/2024. During the visit, there were four (4) clients, and one (1) staff present.

The facility is made up of a one-story home with two (2) client bedrooms, two (2) bathrooms, family room, dining area, kitchen, and an attached garage. LPA conducted a tour of the interior and exterior, and reviewed facility documents. LPA observed the following:

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Client bathrooms have a working toilet, wash basins, and were equipped with a grab bar in the shower. The facility has clean towels, blankets, and linen, available in different colors for each client. LPA tested the water temperature in client bathrooms, which measured at 112- and 114-degrees Fahrenheit.

Kitchen: LPA observed a sufficient supply of dishes, glasses, utensils, pots, and pans. Sample menu is posted on refrigerator door. The stove is operational. Refrigerator and freezer were in working condition. LPA observed the minimum required supply of perishable and non-perishable food available for the clients. A fire extinguisher was charged and mounted near the kitchen.

Laundry: Laundry area had an operable washer and dryer.

Continued on LIC809-C..
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CLEAR HEARTS
FACILITY NUMBER: 331881084
VISIT DATE: 06/19/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Centrally Stored Medications: LPA observed a first aid kit with required components. Cleaning solutions, sharps, knives, and Client medications are secured in a hallway closet, equipped with a pin pan door lock.

Living/Family room: The family room had a working television and various books and board games available for the clients in care. Fireplace in the living room has appropriate cover and is inaccessible to clients in care. Emergency phone numbers and facility sketch were posted in the hallway. Facility did not have Let-Us-No Poster, but Licensee printed the form and immediately added it to the hallway postings.



Yard/Outside Area: Shaded outside seating is available for the clients. A brick wall secured the entire backyard. All outdoor pathways were free of obstructions. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

There were no deficiencies noted at the time of the visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee Roldan.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2