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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881102
Report Date: 04/16/2021
Date Signed: 04/16/2021 11:25:17 AM

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:PRUDENCE SENIOR LIVINGFACILITY NUMBER:
331881102
ADMINISTRATOR:GOFFUR, EFAZFACILITY TYPE:
740
ADDRESS:23595 TAFT COURTTELEPHONE:
(951) 742-1742
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:6CENSUS: 0DATE:
04/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Efaz Goffur, LicenseeTIME COMPLETED:
10:30 AM
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Licensing Program Analyst Deborah Mullen conducted an announced pre-licensing inspection. A tele-visit was conducted due to Covid-19 restrictions. This home is currently licensed and in operation with 0 residents in care.

The home is a (6) bedroom, (2) bath home with a living room, family room, and dining room/kitchen. Per the approved fire clearance, the licensee is approved for 4 non-ambulatory and 2 bedridden residents and all rooms are approved for either ambulatory, non-ambulatory and/or bedridden. All bedrooms are furnished with bed, night stand and dresser. Bedrooms have adequate lighting for residents’ use. Fire extinguisher was present and fully charged. The kitchen was observed to have pots and pans. Knives other sharp utensils will be stored in the locked pantry. Staff and resident files as well as resident's medications, will be kept in a locked cabinet in the office. A complete first aid kit was observed to be present in the home. Chemicals and cleaners will be locked and stored in the garage. The backyard was observed to be fully fenced with an unlocked gate. The back yard has a covered patio for resident's comfort.

LPA discussed the following items needed in the home:
  • An adequate supply of towels and linens for six residents.
  • A chair in each of the residents bedrooms
  • Silverware and dishes for six residents
  • Cooking utensils and bowls/serving dishes for meals
  • Patio table and chairs for six residents
  • Posting of the following documents in a public location: personal rights; emergency evacuation plan with emergency telephone numbers; visitation policy; theft and loss policy; Ombudsman poster; Residential Care Facility for the Elderly Complaint Poster (PUB 475).

Licensee will submit pictures for proof of correction. Once all items have been corrected the home will be ready for licensure. An exit interview was conducted, and a copy of this report was emailed to Mr. Goffur for his review and signature.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
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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