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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881275
Report Date: 03/24/2022
Date Signed: 03/24/2022 03:10:57 PM

Document Has Been Signed on 03/24/2022 03:10 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:SMITH FAMILY HOMEFACILITY NUMBER:
331881275
ADMINISTRATOR:ANTAR, ALI JR.FACILITY TYPE:
735
ADDRESS:35876 NEALA LANETELEPHONE:
(951) 370-9212
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY: 4CENSUS: 0DATE:
03/24/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Mona Ayad, LicenseeTIME COMPLETED:
03:20 PM
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Licensing Program Analysts (LPAs) Tricia Danielson and Chinwe Nwogene conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPAs met with Licensee Mona Ayad. An initial application to operate an Adult Residential Facility (ARF) was received by the Central Applications Bureau (CAB) on 12/9/21 for a total capacity of four (4) ambulatory clients. Fire Clearance was granted for four (4) ambulatory clients on 2/1/2022. LPAs observed the following:
Structure:
Facility was a two story house with three (3) client bedrooms, two (2) bathrooms, family room, 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 upstairs hallway to control entire house.
Bedrooms:
Each client bedroom will accommodate any ambulatory client. All client bedrooms were adequately furnished with bed, chair, closet, clothing storage, adequate lighting, and an operable smoke alarm/carbon monoxide detector.
Bathrooms:
Both bathrooms have a working toilet, wash basin, and shower. At 2:38 PM, LPAs began testing water temperatures in client bathrooms. LPAs verified water temperatures were measured at 117 and 118 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies were secured in a locked cabinet in the upstairs laundry room. Knives/sharp instruments will be stored in a locked file cabinet. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition
(CONTINUED ON LIC 812C)
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
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: SMITH FAMILY HOME
FACILITY NUMBER: 331881275
VISIT DATE: 03/24/2022
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(CONTINUED FROM LIC 812)
and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry area with washer and dryer were located in a separate room upstairs.
Living/Family room:
There was a family room with safe and adequate seating for all clients as well as working TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in the upstairs cabinet.
Yards/Outside:
Fencing secured the entire backyard. All outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property.
Garage:
Garage was being utilized with packed boxes in preparation of Licensee's move.
Emergency Phone Numbers, and Exit Plan:
Let-Us-No poster, emergency phone numbers, and facility sketch were posted in the kitchen/family room area.
General items:
Two (2) fire extinguisher were charged and mounted in entry way and upstairs hallway. Smoke alarms/carbon monoxide detectors were tested and were in working order. Client records will be stored in a locked file cabinet. First Aid kit with required components, and locked area for medication storage was observed. There were no firearms or ammunition observed at the facility and LPAs were informed the facility will not store firearms or ammunition on the premises.
Component III was completely during today's visit and a hard copy was provided as well for reference. Pre-Licensing is not complete at this time. The following corrections must be made in order to meet licensing requirements:
provide covered patio seating for 4 clients
post a sample menu
post an activity schedule
personal rights poster
night stand in double room
emergency flashlights
emergency food and water supply
An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
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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