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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881257
Report Date: 08/07/2024
Date Signed: 08/07/2024 09:01:09 AM

Document Has Been Signed on 08/07/2024 09:01 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:OSLO HOMEFACILITY NUMBER:
331881257
ADMINISTRATOR/
DIRECTOR:
CLOYD, SHILOHFACILITY TYPE:
735
ADDRESS:3678 OSLO CTTELEPHONE:
(619) 292-9299
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 4CENSUS: 2DATE:
08/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:40 AM
MET WITH:ADMINISTRATOR, SHILOH CLOYDTIME VISIT/
INSPECTION COMPLETED:
09:08 AM
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On August 07, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced at the facility to conduct the Required Annual visit, and met with Administrator. LPA introduced herself and stated the purpose of the visit. The annual facility file was conducted in the Regional Office and additional records were reviewed on site. The facility is licensed for four Adults and is currently operating at a census of two Adult (735).

LPA Mixson toured the facility along with Administrator and made observations following is a summary of today’s visit. LPA inspected the facility inside and outside, there were no obstructions or debris to the indoor or outdoor passageways currently at the time of this visit. The facility is a single-story home located at 3678 Oslo Ct Hemet, CA. 92545.

Physical Plant: The facility phone number is (951) 260-3771 and it is operable. LPA observed residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something" and the "Personal Rights." The cleaning supplies and sharp items were kept locked and inaccessible to the resident in care. There was a designated storage space for the residents' and staff files, and it was locked and inaccessible to resident in care currently at the time of this visit.

Medications: Were locked and inaccessible to resident in care, and there was a sufficient supply of medications. The overall facility is clean, the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit, and there were safety lights for night throughout the facility.

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked.

Care & Supervision: Facility has sufficient staff, four staff on site at the time of this visit, and no residents due to being at the Day Program.

Records Review: LPA Mixson reviewed two resident file and two staff files, conducted two staff interviews and no resident interviews. Previous Community Care Licensing forms were reviewed. There was no Title 22, Division 6 Regulation violations observed or cited during today’s visit.

An exit interview was conducted, and a copy of this report was discussed and given to Administrator, Shiloh Cloyd.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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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