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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881247
Report Date: 02/28/2024
Date Signed: 02/28/2024 12:52:39 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/28/2024 12:52 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:COVENANT LOVING CAREFACILITY NUMBER:
331881247
ADMINISTRATOR:BOLADELE IGEFACILITY TYPE:
735
ADDRESS:937 ASTER STREETTELEPHONE:
(213) 820-4701
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 4CENSUS: 0DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Justine ThomasTIME COMPLETED:
01:00 PM
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On 2/28/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced annual required visit to the facility. LPA knocked on the front door and did not receive a response. LPA contacted Licensee, Justina Thomas over the phone and explained the purpose of the visit. Licensee stated they were not available to meet LPA at the facility, but would have a family member meet LPA at the facility to grant the Department entry and allow LPA to conduct the annual inspection. Licensee informed LPA that the facility is pending client placement at the facility.

LPA conducted a tour of the facility's interior and exterior and did not observe any signs to suggest the home is currently occupied. The facility has a fire clearance to care for four (4) non-ambulatory clients and serves adults ages 18 through 59. During the tour, LPA observed the facility is made up of a one-story home with four (4) bedrooms, two (2) bathrooms, family room, dining area, kitchen, and an attached garage.

The smoke alarms and carbon monoxide detectors were tested and found to be operational. The facility has charged fire extinguishers mounted throughout the home. LPA observed client bedrooms were each furnished with a bed, chair, closet, clothing storage and had functional lighting. Client bathrooms have a working toilet and wash basin. LPA observed additional clean towels, blankets, and linen, available in different colors for future client use. LPA observed a sufficient supply of dishes, glasses, utensils, pots, and pans for the facility's approved capacity.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: COVENANT LOVING CARE
FACILITY NUMBER: 331881247
VISIT DATE: 02/28/2024
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 The stove is operational. Refrigerator and freezer are in working condition. LPA observed storage space for a 2-day supply of perishable food items and 7-day supply of non-perishable food items. LPA observed designated areas to secure medications, sharps and disinfectants. The family room had a working television. A brick wall secured the entire backyard. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted over the phone and LPA reviewed the report with Licensee. LPA will email a copy of this report to Licensee for their signature. Licensee agreed to inform LPA when clients are placed in the home.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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