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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881285
Report Date: 05/10/2022
Date Signed: 05/10/2022 04:03:31 PM


Document Has Been Signed on 05/10/2022 04:03 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:BETTY'S PLACEFACILITY NUMBER:
331881285
ADMINISTRATOR:BERG, MCCLAINFACILITY TYPE:
740
ADDRESS:37182 SIERRA GROVE DRIVETELEPHONE:
(951) 316-1549
CITY:MURIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 0DATE:
05/10/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Licensee- McClain BergTIME COMPLETED:
04:20 PM
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On 05/10/2022 Licensing Program Analyst (LPA) Janira Arreola conducted an announced visit for the purpose of a pre-licensing inspection. LPA met with Licensee, McClain Berg and was granted entry. LPA took a tour of the interior and exterior of the home. The home will be licensed for a total capacity of (6) residents, ages 60 and older. LPA noticed Fire Clerance dated (3/30/2022) was approved for 6 bedridden residents and it was not noted on the comments on the facility profile. LPA also was provided with Hospice waiver for 6 resident and dementia plan that was also not included in the comments. LPA will reach out to CAB Analyst to have this corrected.

LPA was informed that no firearms or ammunition will be kept at the facility. There are also no bodies of water, such as pools at the facility. LPA observed the home as follows: The home isa single story 6 bedroom and 4 bathroom home with an attached garage and laundry room. Each bathroom had soap, and sturdy grab bars. LPA advised licensee to obtain a trash bin with a lid, paper towels, hand washing posters in all 4 bathrooms and to obtain anti-slip mats in the showers. All 6 bedrooms have a night stand, bed, and closet space. LPA advised Licensee to obtain a reading lamp for Bedroom 3. LPA observed alarm system on all doors leading to the exterior of the home to ensure resident safety. There were handrails in the hallways and the appropriate postings were posted at the facility.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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: BETTY'S PLACE
FACILITY NUMBER: 331881285
VISIT DATE: 05/10/2022
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LPA observed enough personal hygiene supplies including deodorant, shampoo, tooth brushes, toothpaste and body wash. LPA advised Licensee to get full sized hygiene supplies when residents are admitted. The dining area had 6 chairs, and the outdoor seating area also has 6 chairs and an umbrella for shade. LPA tested the hot water temperature which was 107 degree Fahrenheit. LPA observed a 2 day supply of non-perishable foods and enough plates, cups, and silverware for 6 residents. LPA will give the Licensee a technical advisory for not have a 7 day supply of perishable foods. LPA observed sharp objects in locked closet designated for resident medicine.

This report was reviewed with Licensee McClain Berg and copy of the report was provided as well.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC809 (FAS) - (06/04)
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