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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881104
Report Date: 04/08/2024
Date Signed: 04/08/2024 01:05:55 PM

Document Has Been Signed on 04/08/2024 01:05 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GRAYSTONE RESIDENTIAL CAREFACILITY NUMBER:
331881104
ADMINISTRATOR/
DIRECTOR:		RANDLE, DEANAFACILITY TYPE:
735
ADDRESS:27630 GRAYSTONE LANETELEPHONE:
(951) 696-7496
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 4CENSUS: 3DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Licensee, Deana RandleTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 4/8/2024, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct an annual required inspection. LPA was greeted and granted entry by Lead Staff, Melina Burgueno. Licensee Randle arrived during the visit. LPA was informed clients were at day program.

LPA toured the facility with Lead Staff Burgueno. During the tour, LPA observed the facility is made up of a two-story home with four (4) client bedrooms, two (2) bathrooms, two (2) dining rooms, two (2) living rooms, a laundry room, office and attached garage. The facility has a fire clearance to care for four (4) ambulatory clients and serves adults ages 18 through 59. LPA observed the home is clean and furniture is in good condition. LPA toured the kitchen and observed the facility has a 2-day supply of perishable foods and 7-day supply of non-perishable food items. LPA observed medication is secured in a locked hallway closet. LPA reviewed clients' physical medication along with their Medication Administration Record and did not discover any discrepancies. Lead Staff Burgueno tested the smoke alarm/carbon monoxide detectors and LPA observed them to be operational. LPA observed fire extinguishers mounted throughout the facility, which were serviced on 3/12/2024. The facility's last fire drill was conducted on 2/11/2024 and earthquake drill on 3/27/2024. The facility has emergency food supplies, water and backpacks available for the clients. The facility safeguards the clients' cash resources. LPA reviewed the Record of Client's/Resident's Safeguarded Cash Resources (LIC405) along with the clients' physical monies and did not discover any discrepancies. LPA reviewed random client and staff files. Client files reviewed had updated Individual Program Plans and signed admission agreements. Staff files reviewed had the required training records, criminal record clearance and valid first aid certification. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Licensee Randle.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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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