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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881084
Report Date: 06/14/2024
Date Signed: 06/14/2024 01:51:30 PM

Document Has Been Signed on 06/14/2024 01:51 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CLEAR HEARTSFACILITY NUMBER:
331881084
ADMINISTRATOR/
DIRECTOR:		ROLDAN, TIANYAFACILITY TYPE:
735
ADDRESS:327 PINNACLE STTELEPHONE:
(951) 490-4080
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 4CENSUS: 3DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:36 AM
MET WITH:HOUSE MANAGER, TIANYA ROLDANTIME VISIT/
INSPECTION COMPLETED:
01:56 PM
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On June 14, 2024, Licensing Program Analyst (LPA), Venus Mixson conducted an unannounced Required One Year visit, and met with the Administrator, Tianya. The Facility file review was conducted in the Regional Office and additional forms were reviewed on site. The facility is licensed for four Adults, type (735), and is currently serving three Adults.

LPA Mixson toured the facility along, with the Administrator following is a summary. Physical Plant: The facility is a single-story home located at 327 Pinnacle Street, Perris, CA. 92570, and has four resident bedrooms, three bathrooms, a family room, dining area, kitchen, and an attached two-car garage. The facility land line phone number is (951) 490-4080 and it is operable.
Bedrooms: The bedrooms were furnished with the required items per Regulation. There were observable smoke alarm/carbon monoxide detectors, in accordance with California, Code of Regulation, Title 22.
Facility Bathrooms: bathrooms have a working toilet, wash basin, and were equipped with a grab bar and non-slips mats in the shower. The water temperatures tested within regulations. The facility has an sufficient supply of extra liens available to residents in care.
Kitchen: LPA Mixson observed a sufficient supply of dishes, glasses, utensils, pots, and pans. Sample menu is posted in kitchen on the side of the refrigerator. All kitchen appliance, along with the stove is operational. Refrigerator and freezer were in working condition.
Centrally Stored Medications: Medications were locked and inaccessible to the residents in care, and there was a sufficient monthly supply for the residents. LPA Mixson observed a first aid kit with required components, and it was locked and inaccessible to residents in care.

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SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CLEAR HEARTS
FACILITY NUMBER: 331881084
VISIT DATE: 06/14/2024
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Living/Family room: The family room had a working television. "If You See Something Say Something" poster, Long- Term Care Ombudsman poster, emergency phone numbers, and facility sketch were posted at the front door. Hallways were free of obstructions and had night lights throughout.
A fire extinguisher was charged and mounted on the wall next to the kitchen.
Laundry Room: the laundry room had space enough for clean and dirty clothes, along with a washer and dryer and they are operable.

Outside Yard Area: Covered patio seating is available for the residents. All outdoor pathways were free of obstructions and debris currently. There were no bodies of water observed on the property. There were no firearms or ammunition observed at the facility and the Administrator stated there are no firearms or ammunition stored on the premises.

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharps are locked.

Care & Supervision: Facility has sufficient staff, two staff on site at the time of this.

Records Review: LPA Mixson reviewed resident and staff files, conducted staff interviews, and reviewed previous Community Care Licensing forms. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit.

An exit interview was conducted, and a copy of this report was discussed and provided to the Administrator, Tianya Roldan.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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