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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881201
Report Date: 11/16/2021
Date Signed: 11/16/2021 12:26:29 PM

Document Has Been Signed on 11/16/2021 12:26 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:CONCEPT FOR LIFE HOME LLCFACILITY NUMBER:
331881201
ADMINISTRATOR:DUPREE, TIFFANYFACILITY TYPE:
735
ADDRESS:25791 FIR AVETELEPHONE:
(323) 921-8391
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 3DATE:
11/16/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tiffany Dupree, LicenseeTIME COMPLETED:
01:05 PM
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On 11/16/21 Licensing Program Analyst (LPA) Javina George conducted an announced visit for the purpose of conducting a pre-licensing inspection with a change in ownership.

Upon arrival LPA met with Licensee Tiffany Dupree whom assisted with the inspection. The facility is a (2) two story house with (3) three resident bedrooms, 1 staff office and 3 bathrooms, a living room, kitchen with dining area, laundry room, 2 car garage and a backyard. On 8/6/21, the Moreno Valley Fire Department approved the facility for 4 ambulatory residents.

During today's inspection, LPA toured the interior and exterior of the facility. The medications will be centrally stored in the kitchen, and locked inside a cabinet next to the sink. The facility is equipped with lights in the hallways and passages. The smoke and carbon monoxide detectors were tested and are operable. There were 2 fire extinguishers observed.

All cleaning supplies are locked in a closet, in the downstairs hallway. The facility does not have any sharps located on the premises. All doors, and passageways are clear from obstruction. In the backyard there is a pool and jacuzzi that is fenced and locked. There is one fire place; covered with glass. All beds have the required linen and supplies. There was a sufficient amount of clean linen and hygiene items. There was appropriate lighting in each room.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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: CONCEPT FOR LIFE HOME LLC
FACILITY NUMBER: 331881201
VISIT DATE: 11/16/2021
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The hot water tested and ranged from 117-119 degrees F. All kitchen appliances operate properly. The bathrooms are equipped with non-skid floor mats and/or surfaces.

All garbage cans have tight fitting lids. The facility is stocked with a 2 day supply of perishables and a 7 day supply of non-perishable food items. The facility was stocked with dishes, tableware, and utensils in good repair and enough for the capacity.

The resident files will be locked in a 2 drawer file cabinet located inside of the living room. LPA observed the emergency disaster plan, facility sketch, personal rights, and complaint procedures that are hung on the wall located in the living room before entering the kitchen.

There is adequate seating in the common areas. There is 1 stocked first aid kit with 1 manual. The facility is stocked with activities (gaming system, and board games) to provide entertainment and encourage socialization for the residents and are located in the living room.
Composition III orientation was also completed after the inspection.

The facility is ready to be licensed.

An exit interview was conducted and a copy was at the facility with Licensee Tiffany Dupree.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
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