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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881166
Report Date: 08/18/2021
Date Signed: 08/18/2021 12:15:00 PM

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:TRANQUALITY VALLEY ASSISTED LIVINGFACILITY NUMBER:
331881166
ADMINISTRATOR:FUENTES, TERESAFACILITY TYPE:
740
ADDRESS:26450 HELENE DRIVETELEPHONE:
(404) 934-2560
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:6CENSUS: 0DATE:
08/18/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Teresa Fuentes, Licensee/AdministratorTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Tricia Danielson conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 11:10 AM, LPA met with Licensee/Administrator Teresa Fuentes. An initial application to operate a Residential Care For the Elderly (RCFE) facility was received by the Central Applications Unit (CAU) on 05/13/21 for a total capacity of six (6) non-ambulatory residents. Fire Clearance was granted on 07/15/21 for six (6) non-ambulatory residents. During today's visit, LPA Danielson observed the following:
Structure:
Facility was a single story house with three (3) resident bedrooms, two (2) resident bathrooms, living room, family room, dining area and kitchen. There was an attached three (3) care garage in the front of the house. The facility also has a bedroom and bathroom designated for live in staff.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each resident bedroom will accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm/carbon monoxide detector.
Bathrooms:
The two (2) resident bathrooms have a working toilet, wash bash and an adequate supply of paper towels, toilet paper, and soap. LPA verified bathroom water temperatures were measured at 111.8 and 112.7 degrees Fahrenheit.
(CONTINUED ON LIC 812C)
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: TRANQUALITY VALLEY ASSISTED LIVING
FACILITY NUMBER: 331881166
VISIT DATE: 08/18/2021
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(CONTINUED FROM LIC 812)Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies were secured in the locked cabinet under the sink. Knives/sharp instruments were secured in a locked cabinet. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all residents.
Living/Family room:
There was a living room with safe and adequate seating for all residents as well as working TV.
Linens and Hygiene Supplies:
An adequate supply of additional linens and medical supplies were stored in a hallway cabinets.
Yards/Outside:
There was a patio with adequate covered seating for all residents. All walkways were observed to be free of obstructions.
Garage:
Garage was free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Let-Us-No poster, emergency phone numbers, emergency exit plan, resident Personal Rights, and facility visitation policy were posted as required.
General items:
Two (2) fire extinguishers were charged and located in the kitchen/dining room and hallway. Smoke alarms and carbon monoxide detectors were in working order. Resident records will be stored in a locked cabinet. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Component III was completed during today's visit and a copy was also emailed to Licensee.
There are no deficiencies noted. Licensure will be granted based on final approved from CAU. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
LIC809 (FAS) - (06/04)
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