331881165-9-29-2023-18-AS-SMAZ-CW5TWM-20230929150547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881165
Report Date: 09/29/2023
Date Signed: 09/29/2023 03:06:04 PM

Document Has Been Signed on 09/29/2023 03:06 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	DNM WOLLYLEAF		FACILITY NUMBER:	331881165
ADMINISTRATOR:	MILES, WILTON		FACILITY TYPE:	735
ADDRESS:	3013 WOLLYLEAF CT		TELEPHONE:	(951) 563-5230
CITY:	PERRIS	STATE: CA	ZIP CODE:	92571
CAPACITY: 4		CENSUS: 3	DATE:	09/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:36 PM
MET WITH:	Wilton Miles - Administrator		TIME COMPLETED:	03:14 PM

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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with staff, Kaylon Miles and Terrah Divens, who was informed of the purpose of the visit. Administrator Wilton Miles arrived shortly after to assist LPA. At the time of the visit there was two (2) staff and two (2) clients present.

The facility is a two story home with four (4) bedrooms and four (4) bathrooms with an attached garage, and a backyard. The downstairs area contains four (4) bedrooms and three (3) bathrooms. The upstairs area has the staff office and one (1) bathroom. The facility does not have any bodies of water, firearms, or ammunition on the property. The clients served are adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical Plant: LPA observed the client bedrooms, bathrooms, and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards and contained outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 116F.

Food Service: 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.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DNM WOLLYLEAF	FACILITY NUMBER: 331881165
	VISIT DATE: 09/29/2023

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Record Review and Resident/Staff Files: LPA reviewed three (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a hallway closet. LPA reviewed medications for three (3) client and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills was conducted on 07/11/2023, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Administrator, Wilton Miles.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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