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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881180
Report Date: 11/21/2023
Date Signed: 11/21/2023 01:03:41 PM

Document Has Been Signed on 11/21/2023 01:03 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: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:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Comfort Olaniyan, CaregiverTIME COMPLETED:
01:10 PM
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On 11/21/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Caregiver, Comfort Olaniyan who was informed of the purpose of visit. LPA also spoke to Administrator, Oluwakemi Alofe via telephone call. At the time of visit there was 1 staff and 2 residents present. LPA was informed one #1 client is at the Day Program. LPA toured the facility inside and out with Comfort Olaniyan.

Tour included:

Kitchen; LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the census. The refrigerator and stove are in working order. Sharps are stored in a locked closet, available only to authorized individuals. Fridge, freezer, and all need appliances were present and shown to be in working condition and clean.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 68 degrees Fahrenheit.



Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medications; LPA observed medications were labeled and stored in separate bins inside of a locked medication cabinet and are distributed according to physician orders. The first aid kit was complete.



Continue on LIC809-C
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALICE CARE RESIDENTIAL HOME INC.
FACILITY NUMBER: 331881180
VISIT DATE: 11/21/2023
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Continued from LIC809.

Bathroom; LPA toured hall bathroom and observed bathroom to be clean. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 114 degrees Fahrenheit.

Bedroom; LPA toured four #4 out of #4 residents bedrooms and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs. Resident #1 bedroom has a private bathroom. LPA observed bathroom to be clean and hot water was measured at 114 degrees Fahrenheit.

Garage; LPA tour the garage and observed garage to be clean and not cluttered.

Laundry; Cleaning supplies are stored away in the laundry room, inaccessible to clients, washing machine and dryer are all in good repair and sufficient for the census.

Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gate remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents. Fridge and freezer are large enough to accommodate required perishable foods.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Three #3 staff and #3 residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility.

Interview; one #1 staff and two #2 residents were interviewed.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Comfort Olaniyan.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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