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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881135
Report Date: 03/07/2024
Date Signed: 03/07/2024 01:38:17 PM


Document Has Been Signed on 03/07/2024 01:38 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:RISING STAR CARE HOME LLCFACILITY NUMBER:
331881135
ADMINISTRATOR:REED, JAMES E.FACILITY TYPE:
740
ADDRESS:40600 CHANTEMAR WYTELEPHONE:
(951) 506-4002
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY:6CENSUS: 5DATE:
03/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, James ReedTIME COMPLETED:
02:00 PM
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On 3/7/2024, 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 Administrator, James Reed who was informed of the purpose of the visit.
During LPA's visit, there was five (5) residents and two (2) staff present. Staff present had a criminal record clearance, the required training records and a valid first aid certification on file. LPA observed residents watching television in the living room and resting in their rooms. LPA conducted a tour of the facility's interior and exterior with Administrator Reed. The facility is made up of a one story home with three (3) resident bedrooms, two (2) bathrooms, a kitchen, dining room, living room and an attached garage. The facility is licensed to care for six (6) non-ambulatory elderly residents, of which one (1) may be bedridden. The facility also has an approved hospice waiver for six (6) residents and LPA was informed there are currently four (4) residents receiving hospice services at the facility. Administrator Reed tested the smoke/carbon monoxide detector and LPA found it to be operational. LPA also observed charged fire extinguishers mounted throughout the facility. Indoor and outdoor passageways are free of obstruction and the physical plant is in good repair. There are no bodies of water on the premises. The living room fireplace had an appropriate barrier to make it inaccessible for the residents. The facility met Departmental requirements for a 2-day supply of perishable food and 7-day supply of non-perishable food items. Emergency food, water and additional incontinent supplies are stored in the garage. Medications are secured in a locked kitchen cabinet and the facility has a complete first aid kit. Cleaning solutions and disinfectants are secured in the garage. During today's visit, LPA did not issue any deficiencies. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Reed.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
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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