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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881275
Report Date: 06/14/2023
Date Signed: 06/14/2023 11:18:23 AM

Document Has Been Signed on 06/14/2023 11:18 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SMITH FAMILY HOMEFACILITY NUMBER:
331881275
ADMINISTRATOR:JANICE BARNESFACILITY TYPE:
735
ADDRESS:35876 NEALA LANETELEPHONE:
(951) 370-9212
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY: 4CENSUS: 0DATE:
06/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Mona AyadTIME COMPLETED:
11:30 AM
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On Wednesday, 6/14/2023, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced annual required visit to the facility at 10:00 a.m. LPA was granted entry by Licensee Mona Ayad who was informed of the purpose of the visit. Fire clearance was granted for four (4) ambulatory clients; however, no clients are currently in care at the facility. The clients served will be adults between the ages of 18-59.

The facility is made up of a two-story home with three (3) client bedrooms, two (2) bathrooms, family room, dining area, kitchen, and an attached garage. LPA conducted a tour of the interior and exterior, and reviewed facility documents. LPA observed the following:

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage, lighting, and an operable smoke alarm/carbon monoxide detector, in accordance with Title 22 regulations.

Bathrooms: Both bathrooms have a working toilet, wash basin, and were equipped with a grab bar and non-slips mats in the shower. LPA tested water temperatures in client bathrooms and water temperatures were measured at 112- and 116-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for each client.

Kitchen: LPA observed a sufficient supply of dishes, glasses, utensils, pots, and pans. Sample menu is posted on kitchen wall along with an activity schedule. The stove is operational. LPA observed sufficient room for non-perishable food storage. Refrigerator and freezer were in working condition and had plenty of storage for perishable food.

Continued on LIC809-C...
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SMITH FAMILY HOME
FACILITY NUMBER: 331881275
VISIT DATE: 06/14/2023
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Laundry: Laundry area had a washer and dryer in a separate room upstairs.

Centrally Stored Medications: LPA observed a first aid kit with required components, and locked area for medication storage.

Living/Family room: The family room had a working television. Let-Us-No poster, emergency phone numbers, and facility sketch were posted in the kitchen/family room area. Client records will be stored in a locked file cabinet in the family room.



Hallway: Upstairs hallway was free of obstructions. Two (2) fire extinguishers were charged and mounted in entry way and upstairs hallway.

Yard/Outside Area: Covered patio seating is available for four (4) clients. Fencing secured the entire backyard. All outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property. 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.

Garage(s): Garage is being utilized with packed boxes in preparation of Licensee's move.

Technical Advisories: LPA observed a knife in a kitchen drawer that was not secured. LPA observed dish soap and a bottle of cleaning solution under kitchen sink that was not secured. LPA also observed unsecured cleaning solutions and laundry detergents in the upstairs laundry room’s top shelf. LPA observed two 15 pound cast iron kettlebells near the trash can located in the patio area.

Licensee agreed to secure knives, sharp instruments, laundry detergents and cleaning solutions to make them inaccessible for future clients. Licensee agreed to remove both 15 pound weights in patio area.

An exit interview was conducted, and a copy of this report was provided to Licensee Ayad.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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