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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881265
Report Date: 03/29/2022
Date Signed: 03/29/2022 12:39:30 PM

Document Has Been Signed on 03/29/2022 12:39 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SRI PARK VIEWFACILITY NUMBER:
331881265
ADMINISTRATOR:ADAMS, ANDYFACILITY TYPE:
735
ADDRESS:23097 PARK VIEW COURTTELEPHONE:
(818) 635-4820
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 5CENSUS: 0DATE:
03/29/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Andy Adams, Administrator TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 10:00 AM, LPA met with Licensee/Administrator Andy Adams. An initial application for Adult Residential Facilities (ARF) was submitted to the Central Applications Bureau (CAB) on 10/28/2021 for a total capacity of five (5) non-ambulatory residents. Fire clearance was granted on 12/10/2021. LPA Delgado observed the following:
Structure:
Facility was a one-story house with five (5) resident bedrooms, two (2) resident bathrooms, half (1/2) bathroom, living room with dining area and kitchen. There was an attached two car garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each resident bedroom #1, #2, #3, #4 and #5 will accommodate any non-ambulatory resident. 5 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. #5 needs a chair
Bathrooms:
The (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:44 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 106.6 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a tool box located in the hallway closet #1. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition.
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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 3
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: SRI PARK VIEW
FACILITY NUMBER: 331881265
VISIT DATE: 03/29/2022
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(CONTINUED FROM LIC 809)
and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the home. Laundry detergents and cleaning supplies were observed in a locked cabinet in the garage away from residents.
Living/Family room:
There was a living room with seating for all clients and TV in the Great room.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in main hallway #2 of the residence. Hygiene supplies in the storage closet located inside the garage.
Yards/Outside:
Patio table, umbrella, 4 chairs and a bench were observed in the backyard. There was a gate on the North side of the property with a self-latching from the exterior door. All outdoor pathways were free of obstructions. Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the main hallway. Let-Us-No poster, emergency phone numbers and resident rights observed.
General items:
One (1) fire extinguishers were charged and located in the living/dining area. Nine (9) smoke alarms and one (1) carbon monoxide detectors were tested and were observed to be in working order in the main hallway and centrally connected. Client records will be stored in a locked Storage room #1. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply and emergency food supply was not sufficient. Component III was completed on this day as well.

(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
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: SRI PARK VIEW
FACILITY NUMBER: 331881265
VISIT DATE: 03/29/2022
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(CONTINUED FROM 809C)

Pre-Licensing is incomplete and the following corrections to be resolved by 4/5/2022:
obtain additional 72-hour emergency food supply
obtain additional emergency water
obtain 30-Days of PPE supplies specifically face shields, surgical masks and gowns
obtain lock for drawer that is for office supplies in the kitchen area
obtain chair for bedroom #5
obtain five (5) flashlights for resident bedrooms #1-#5
designate resident bedrooms
replace bulb in ceiling fan for bedroom #3
repair window screen for bedroom #4 above the shower

An exit interview was conducted, and a copy of this report was given.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC809 (FAS) - (06/04)
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