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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881192
Report Date: 01/26/2022
Date Signed: 01/26/2022 04:03:50 PM

Document Has Been Signed on 01/26/2022 04:03 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BRODIAEA HOUSEFACILITY NUMBER:
331881192
ADMINISTRATOR:STEWART, CHARLESFACILITY TYPE:
735
ADDRESS:24595 BRODIAEA AVENUETELEPHONE:
(760) 686-7036
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 0DATE:
01/26/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator Charles StewartTIME COMPLETED:
03:31 PM
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Licensing Program Analyst (LPA) Venus Mixson conducted a scheduled visit to the facility for purpose of a Pre-Licensing evaluation. LPA met with the administrator Mr. Charles Stewart.
This visit was conducted on site at 24595 Brodiaea Ave Moreno Valley, CA 92553, and is a single-story house with four resident bedrooms, three bathrooms, a living room, a small office, kitchen, a garage with no entry from inside the house, and a backyard. On 08/11/2021, the Moreno Valley Fire Department approved the facility for 4 ambulatory residents. LPA observed the following:
Structure: Facility was a single-story house with four resident bedrooms, three bathrooms, living room, dining room, garage, and kitchen area,
Heating/Cooling System: Central heating and air conditioning systems.
Bedrooms: Each resident bedroom will accommodate ambulatory only clients. All bedrooms were adequately furnished with bed, chair, closets, appropriate linens, adequate lighting, and an operational smoke alarm.
Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured between 105 and 110 F.
Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
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: BRODIAEA HOUSE
FACILITY NUMBER: 331881192
VISIT DATE: 01/26/2022
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Dining Room/Living Room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.
Linens and Hygiene Supplies: An adequate supply of linens was available.
Yards/Outside: The back was completed was a patio with adequate covered area for providing shade. There were no obstructions. There were no bodies of water observed anywhere on the property.
Garage: Laundry area with washer and dryer were in the garage. Garage was organized and free of obstructions.
Emergency Phone Numbers and Exit Plan: I see something say something poster.
General items: The facility has six Smoke alarms and carbon monoxide detectors combination. These were tested and operational. LPA observed a facility phone, had administrator call the facility phone 951-208-0382 and it was verified to be operational by LPA, and the service is through Spectrum.

LPA reviewed COMPONENT III with the applicant during this Pre-Licensing Inspection and gave the option to ask
questions.

An exit interview was completed, and a copy of this report was signed and left with the administrator Charles Stewart.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
LIC809 (FAS) - (06/04)
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