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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881180
Report Date: 10/22/2021
Date Signed: 10/22/2021 10:49:33 AM

Document Has Been Signed on 10/22/2021 10:49 AM - It Cannot Be Edited

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:ALICE CARE RESIDENTIAL HOME INC.FACILITY NUMBER:
331881180
ADMINISTRATOR:ALOFE, OLUWAKEMI TFACILITY TYPE:
735
ADDRESS:23888 LONE PINE DRIVETELEPHONE:
(951) 208-0344
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 3DATE:
10/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Oluwakemi AlofeTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Stephanie Williams made an announced visit to the facility in order to conduct a pre-licensing inspection due to facility's change of ownership. LPA identified herself to Administrator, Oluwakemi Alofe, who was prompted of the purpose of the visit and who accompanied LPA during the inspection.

The pending application is for an Adult Residential Facility. The facility has been granted a fire clearance for a total capacity of four ambulatory clients by the City of Moreno Valley Fire Department on 07/29/2021. The facility has a total of four client bedrooms, two and a half bathrooms, a kitchen/dining area, a living room, family room, laundry room, backyard, and attached garage. LPA toured the interior and exterior areas of the facility. The following was inspected:

LPA inspected client bedrooms; the bedrooms have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. LPA inspected resident bathrooms; the bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients. LPA inspected the kitchen; knives, cleaning supplies, and toxins were inaccessible to residents and stored away from food supply. Dishes, glasses, and utensils were in good condition and stored in a safe manner. The kitchen countertops and appliances were free from debris. There was also a sufficient food supply and posted meal menu. LPA inspected the common areas; LPA observed a charged fire extinguisher, operating smoke detectors, and carbon monoxide alarms at the time of visit. LPA observed required postings including complaint procedures, residents personal rights, and the facility's emergency/disaster plan. The facility was equipped with a complete first aid kit. There was a locked and centralized storage area for medications. The facility had a designated area for client files and staff files. The facility had a working telephone for resident use. There was adequate seating in the common areas. LPA inspected the outdoor space; there are no bodies of water on the property and there was a shaded area for residents. LPA observed that side gates were unlocked and kept free of obstruction.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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: ALICE CARE RESIDENTIAL HOME INC.
FACILITY NUMBER: 331881180
VISIT DATE: 10/22/2021
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Overall, the physical plant was clean, in good repair, and appeared to be hazard-free at the time of visit. LPA has determined that the facility has met operational requirements for clients in care.

The pre-licensing inspection is complete and this facility has no deficiencies. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations. LPA has determined to waive Component III of the Department's application process.

An exit interview was conducted where this report was discussed and a copy was provided to Alofe at the conclusion of the inspection.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
LIC809 (FAS) - (06/04)
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