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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881095
Report Date: 05/15/2024
Date Signed: 05/15/2024 11:33:06 AM


Document Has Been Signed on 05/15/2024 11:33 AM - 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:IVY PARK AT MURRIETAFACILITY NUMBER:
331881095
ADMINISTRATOR:BORJA, JINA L.FACILITY TYPE:
740
ADDRESS:27100 CLINTON KEITH ROADTELEPHONE:
(951) 477-5678
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:137CENSUS: 109DATE:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Acting Executive Director, Calais AnguianoTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced to the facility in order to conduct the required annual. LPA met with Administrative Staff, Calais Anguiano who was informed of the purpose of the visit.

The facility is a (2) story building with comprised of resident rooms, bathrooms, activity spaces, outdoor spaces, kitchen and dinning areas. There is a memory care area and assisted living area. No pools or firearms are being kept at the facility. The facility is an residential care facility for the elderly.

The LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Physical plant, floors, windows, and doors were observed to be clean. LPA observed house keeping staff conducting cleaning of the facility during the visit. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. Hot water temperature was recorded in a resident restroom at 113.8F.



LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. There is separation between cleaners and food items.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: IVY PARK AT MURRIETA
FACILITY NUMBER: 331881095
VISIT DATE: 05/15/2024
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Adequate staff are present for the supervision of residents during the visit. LPA reviewed (6) staff files and training as well as (5) client files. Flies possessed all required paperwork. All client medication was locked in medication carts. LPA reviewed MARS sheets for (5) clients and found medication was accounted for.

LPA reviewed documentation showing the facility's last fire drill 5/2/2024, which met the department requirements. LPA observed all facility exits were clear from obstructions and had require evacuation chair. LPA reviewed documentation of operational smoke and carbon monoxide detector conducted on 2/15/2024. LPA observed emergency supplies and first aid kit.

No deficiencies were cited at the time of the visit. An exit interview was conducted with Calais Anguiano where this report was reviewed and provided.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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