331881212-12-1-2021-18-AS-STOS-C9AUYH-20211201145958

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881212
Report Date: 12/01/2021
Date Signed: 12/01/2021 03:00:06 PM

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:	DELICARE HEALTH SERVICES		FACILITY NUMBER:	331881212
ADMINISTRATOR:	AWAD, SAMEH		FACILITY TYPE:	740
ADDRESS:	31416 CHEMIN CHEVALIER		TELEPHONE:	(909) 559-7200
CITY:	TEMECULA	STATE: CA	ZIP CODE:	92591
CAPACITY:	6	CENSUS: 5	DATE:	12/01/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Sameh Awad, Licensee/Administrator		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Stephanie Torres, conducted an announced pre-licensing inspection at the facility. The LPA met with Licensee/Administrator, Sameh Awad. There are currently five (5) residents in care. Application: The change of ownership application is for a Residential Care Facility for the Elderly (RCFE). The fire clearance has been granted for six (6) non-ambulatory residents, of which one (1) may be bedridden. Buildings and Grounds: The home is composed of five (5) resident bedrooms, one (1) staff room, two (2) and a half (1/2) bathrooms, a laundry room, a garage, a living room, kitchen and dining areas, and front/back yard areas. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Awad, there are no weapons stored in the home. Rooms, furniture, beds, mattresses are all in good repair. The bedrooms are furnished, and privacy is available. The dining and living room areas/furniture are clutter free and in good condition. Bathrooms were observed to have non-slip flooring available. Outdoor areas had sufficient room for activities. A washing machine and dryer are available and in working order. Storage and Supplies: Medications will be stored inaccessible to any unauthorized individuals. Secured areas are available for facility, staff, and resident files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored in the garage, inaccessible to unauthorized individuals. Linens, and equipment are all in good repair and sufficient for approved census. A Fire extinguisher was available and fully charged. Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps will be stored in a locked kitchen drawer, available only to authorized individuals. Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E),

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DELICARE HEALTH SERVICES	FACILITY NUMBER: 331881212
	VISIT DATE: 12/01/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Theft and Loss Policies, Visitors Policy, Personal Rights, Resident/Family Council, Facility Sketch (LIC 999), Labor Law Information, and Complaint Information.

The following was observed to require correction: Hot water temperature measured 76.8 degrees Fahrenheit and should be between 105- and 120-degrees Fahrenheit.

The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensure once proof of corrections is received from the applicant. This report was discussed with and a copy provided to Awad.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2