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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881279
Report Date: 03/06/2023
Date Signed: 03/06/2023 12:38:02 PM

Document Has Been Signed on 03/06/2023 12:38 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TRILLIUM HOMEFACILITY NUMBER:
331881279
ADMINISTRATOR:OWENS, OMORODIONFACILITY TYPE:
735
ADDRESS:23093 TRILLIUM DRIVETELEPHONE:
(714) 392-1860
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY: 4CENSUS: 0DATE:
03/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Omorodion OwensTIME COMPLETED:
12:50 PM
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Licensing Program Analysts (LPAs) Victoria Chitgian and Michelle Echeverria made an unannounced visit to conduct a Required Annual inspection. LPAs met with the licensee Omorodion Owens. This Adult Residential facility is licensed for four (4) ambulatory clients.
LPAs observed that there are currently no clients admitted to the facility. Licensee stated the facility intends to continue to be licensed. LPAs toured the facility inside and out. There are no pools, bodies or water, firearms or ammunition. LPAs observed the facility is kept at a comfortable temperature. Hot water was measured in the kitchen sink at 105 degrees Fahrenheit. LPAs observed non-skid mats or strips in showers and tubs. The client bedrooms have the required furniture and functional lighting.
LPAs observed a sufficient supply of towels, linens and personal hygiene items. Cleaning supplies were observed to be locked in the garage. The facility’s smoke detectors and carbon monoxide detectors were tested and are in working condition.
LPAs observed the kitchen to be clean and free of odor and all food is stored in a healthful manner. Appliances were observed to be operating. Frozen and refrigerated food is sealed correctly and protected against contamination. LPAs observed an appropriate food supply of 7-day non-perishable food in a pantry.
LPAs observed where the client’s medications would be centrally located. Medication cabinet is observed to be secured and inaccessible to clients. The facility plans to have an appropriate number of staff present in the during operating hours and during the evening/sleeping hours when admitting clients in care.
LPAs reviewed facility files, signs, and required forms were seen posted. All files were organized and complete. The facility had a first aid kit and manual available.
The patio area is shaded and has tables and chairs for client’s comfort. The back yard is completely enclosed and revealed no immediate hazards or obstructions.

No deficiencies cited per Title 22, Division 6 of the California Code of Regulations at this time.
An exit interview was conducted where this report was discussed and provided to Licensee Omorodion Owens.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2023
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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