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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881237
Report Date: 03/24/2022
Date Signed: 03/24/2022 11:10:37 AM

Document Has Been Signed on 03/24/2022 11:10 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:OUR LEGACY LLCFACILITY NUMBER:
331881237
ADMINISTRATOR:RODRIGUEZ, JEANNETTEFACILITY TYPE:
740
ADDRESS:13000 WILD SAGE LNTELEPHONE:
(951) 575-7775
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 0DATE:
03/24/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Jeannette Rodriguez, LicenseeTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Jesse Gardner conducted an announced pre-licensing inspection to the facility to complete the pre-licensing inspection and Comp III. LPA arrived at the facility at 09:00 AM and met with Licensee Jeanette Rodriguez. Licensee Rodriguez accompanied LPA on a tour of the inside and outside of the facility.

LPA noted that one room will be shared, and four rooms will have one resident each for a total of 6 residents. The facility is a five bedroom, three bath home with a living room, dining room, and kitchen. Per the approved fire clearance, the licensee is approved for 6 non-ambulatory residents. All bedrooms are furnished with a bed, night stand, dressers and have adequate lighting for residents use.

The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The bathrooms have grab bars and non-skid mats installed. The water temperature was tested and measured between 111.5 to 116.0 degrees Fahrenheit. The smoke alarms and carbon monoxide alarms were tested and are in operating order. LPA observed two fire extinguishers present in the hallway adjacent to the kitchen area as well as in the kitchen and are fully charged. The kitchen was observed to have dishes, silverware and pots and pans. The knives were stored in a locked drawer in the kitchen. The medications will be kept in a locked closet with the resident files.

Continued on LIC809-C

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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: OUR LEGACY LLC
FACILITY NUMBER: 331881237
VISIT DATE: 03/24/2022
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The chemicals will be stored in the locked garage. The backyard was observed to be fully fenced with an unlocked gate and an umbrella/table/chairs combination that will provide shaded area for residents.

Prior to approval, LPA found the Licensee did not have liability insurance, and an emergency disaster plan as required in Title 22 Regulations. Licensee will provide to LPA on a future date.

An exit interview was conducted and a copy of this report was reviewed with and provided to Licensee Jeannette Rodriguez.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
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