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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881180
Report Date: 11/05/2024
Date Signed: 11/05/2024 04:55:51 PM

Document Has Been Signed on 11/05/2024 04:55 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/
DIRECTOR:
ALOFE, OLUWAKEMI TFACILITY TYPE:
735
ADDRESS:23888 LONE PINE DRIVETELEPHONE:
(951) 208-0344
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 3DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:22 PM
MET WITH:Comfort Olanivan-CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Debbie Palacios made an unannounced visit to conduct the required annual inspection. LPA was greeted at the door by Caregiver, Comfort Olaniyan and explained the purpose of the visit. Designated Administrator Adegoke Ayeni arrived shortly. At the time of the visit, two (2) clients were present at the facility. A tour of the facility was conducted inside and out. The facility is approved for four (4) Developmentally Disabled adults ages 18-59; all of whom must be ambulatory.
The facility is a two story home with 4 bedrooms and 2 bathrooms. LPA observed clients bedroom furnishings to be in good repair with adequate lighting. Furniture throughout the house was observed to be in good condition. Clients have clean linen in good repair and sufficient hygiene products to meet their needs. All required postings are placed in a prominent area; facility sketch, exit routes, personal rights, and emergency phone numbers were found posted in the facility. Facility has multiple operating dual smoke alarms and carbon monoxide detector that meet statutory standards. Fire extinguishers were examined and determined to be in compliance; facility has two (2) fire extinguishers dated 07/07/24 and 06/22/24 . All inside and outside passageways are clear of obstructions. There are no pools or bodies of water observed.
LPA observed the kitchen area to be clean and odor free with sufficient dishes and glassware. A two (2) day supply of perishable, and a seven day supply of non-perishable, food items were observed. Hot water was measured at 108.0 degrees F. Temperature in the facility was 70 degrees. There is a locked storage area for medication in the living room.Chemicals and poisons are stored in a locked cabinet in the garage. Staff and client records were reviewed and a staff interview was conducted as well. Client medications were verified to be dispensed as prescribed.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted and a copy of this report was provided to Administrator Ayeni

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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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