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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881291
Report Date: 03/18/2022
Date Signed: 09/23/2022 09:16:11 AM

Document Has Been Signed on 09/23/2022 09:16 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MONUMENT PARK HOME, INCFACILITY NUMBER:
331881291
ADMINISTRATOR:NAVARRO, NELLYFACILITY TYPE:
735
ADDRESS:3365 SEQUOIA CTTELEPHONE:
(951) 347-2401
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 5CENSUS: 0DATE:
03/18/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Nelly Navarro, ApplicantTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an announced pre-licensing inspection at the facility and met with Licensee, Nelly Navarro.

Application: The application is for an Adult Residential Facility (ARF), initial application. The fire clearance has been granted for three (3) ambulatory clients and two (2) non-ambulatory client.

Buildings and Grounds: The home is composed of four (4) client bedrooms, two (2) living rooms, three (3) bathrooms, a laundry room, kitchen and dining areas, garage, and front/back yard areas. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors are in working order. There are no pools or other bodies of water located at the home. According to Navarro, there are no weapons stored in the home. Rooms, furniture, beds, mattresses appeared to be in good repair. The bedrooms are fully furnished, and privacy is available. The dining and living room areas are clutter free and in good condition. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer were available and in working order. The home is in excellent condition.

Storage and Supplies: Medications will be stored in a locked filing cabinet, inaccessible to any unauthorized individuals. Secured areas will be made available for facility files and client files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away in a secured garage cabinet. Linens, and equipment appeared to be in good repair and sufficient for the approved census. Fire extinguishers were available and fully charged.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps will be stored in a locked cabinet, available only to authorized individuals.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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 2
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: MONUMENT PARK HOME, INC
FACILITY NUMBER: 331881291
VISIT DATE: 03/18/2022
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Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610D), Personal Rights, Facility Sketch (LIC 999), and Visitors Policy.

No needed corrections were observed to be needed at time of visit. The Component III was presented to Navarro and completed following the inspection of the home. The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensure. This report was discussed with and a copy provided to Navarro.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
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