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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881247
Report Date: 01/19/2022
Date Signed: 01/19/2022 11:09:33 AM

Document Has Been Signed on 01/19/2022 11:09 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:COVENANT LOVING CAREFACILITY NUMBER:
331881247
ADMINISTRATOR:THOMAS, JUSTINAFACILITY TYPE:
735
ADDRESS:937 ASTER STREETTELEPHONE:
(909) 435-0071
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 4CENSUS: 0DATE:
01/19/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Justina ThomasTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Venus Mixson conducted an announced pre-licensing inspection. LPA met with Administrator Justina Thomas. Currently there are 0 residents in care. The application is for an Adult Residential Facility (ARF) with a capacity of 4 ambulatory residents.
A tour of the facility was conducted inside and out. The facility is a one story, four (4) bedroom, two (2) bathroom home with a living/ dining room, garage and kitchen. There are no pools, bodies of water, firearms or ammunition. LPA observed the bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, shower and tubs were having grab bars added at the time of the visit, and shall be completed before end of visit, but non-skid mats were in place. Hot water in the resident’s bathrooms were measured between 105- and 120-degrees F.
LPA observed food storage and preparation areas. Food preparation areas are clean and sanitary. Refrigerator and freezer are maintained at appropriate temperatures. The kitchen was observed to have dishes, silverware and pots and pans. All appliances are clean and operating properly.

There is a sufficient supply of linens, towels and personal hygiene items. The first aid kit was reviewed; all items are present. LPA observed a dining area where residents will have three meals served. Outdoor space is suitable for resident use and was observed to be fully fenced with an unlocked gate, and shaded area was being added on the day of the visit.

The fire extinguishers are completely charged.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2022
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: COVENANT LOVING CARE
FACILITY NUMBER: 331881247
VISIT DATE: 01/19/2022
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Smoke alarms and carbon monoxide detectors are present and functional. Files and medications will be locked in a cabinet outside of the kitchen. All hazardous materials such as, cleaning and disinfecting supplies, knives, and other sharps are locked and inaccessible to residents. All required forms are posted in a common area. Working land line for resident’s use. 951-260-5713 with service through Spectrum.


Pre-licensing inspection complete. COMP III was completed immediately following the inspection. Facility is ready for licensing. An exit interview was conducted, and a copy of this report was reviewed and provided to the administrator Justina Thomas.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
LIC809 (FAS) - (06/04)
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