<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881221
Report Date: 04/12/2024
Date Signed: 04/12/2024 11:36:46 AM

Document Has Been Signed on 04/12/2024 11:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HEAVENLY HELPERS CAREFACILITY NUMBER:
331881221
ADMINISTRATOR/
DIRECTOR:		GRIFFITH, DWAINFACILITY TYPE:
735
ADDRESS:52994 ASTRID WAYTELEPHONE:
(951) 226-7131
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92532
CAPACITY: 4CENSUS: 0DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Dwain Griffith- AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:47 AM
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) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Dwain Griffith and was granted entry to the facility.

The facility is an Adult Residential Facility (ARF) licensed for a capacity of four (4) ambulatory clients. The facility is defined as level 4i home vendorized by Inland Regional Center (IRC). The current census is zero (0) clients. The facility is currently waiting on program design and placement from IRC. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following:

There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathrooms to be at 108 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. The postings such as the facility license, personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. The cleaning supplies, toxins, sharps, and other dangerous items were kept in an inaccessible to future clients in care. There was a designated storage space for future client files and staff files. The medications will be kept inside a safe near the living room inaccessible to future clients in care. The non-perishable and perishable food supply is sufficient for the future clients in care.

LPA did not review client files due to not having in clients in care. LPA reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HEAVENLY HELPERS CARE
FACILITY NUMBER: 331881221
VISIT DATE: 04/12/2024
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
Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Dwain Griffith.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2