<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881291
Report Date: 05/06/2024
Date Signed: 05/06/2024 02:00:27 PM

Document Has Been Signed on 05/06/2024 02:00 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MONUMENT PARK HOME, INCFACILITY NUMBER:
331881291
ADMINISTRATOR/
DIRECTOR:		NAVARRO, NELLYFACILITY TYPE:
735
ADDRESS:3365 SEQUOIA CTTELEPHONE:
(951) 347-2401
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 5CENSUS: 4DATE:
05/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Licensee, Nelly NavarroTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/6/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to conduct a required annual inspection. LPA met with Licensee, Nelly Navarro who was informed of the purpose of the visit.

During today's visit, there was two (2) staff and two (2) clients present and LPA was informed two (2) clients were at day program. LPA toured the facility's interior and exterior with Licensee Navarro and conducted staff and client interviews.

LPA reviewed random staff and client files. Staff files reviewed had a valid first aid/CPR and Non-violent Crisis Prevention certification. Client files reviewed had signed admission agreements and updated Individual Program Plans and physician's reports. Client bedrooms are clean and have the required bedding, furniture and functional lighting. Bathrooms are clean and have toilet paper, soap, and paper towels readily available. LPA toured the kitchen and observed the facility has a 2-day supply of perishable foods and 7-day supply of non-perishable foods. Knives were secured in a locked kitchen cabinet under the sink. Medication is secured in a locked medication cart, only accessible to staff. LPA toured the garage and observed laundry detergent and disinfectants are secured in a locked storage cabinet. LPA also observed the facility has emergency food, water and backpacks filled with emergency supplies available for the clients. LPA observed fire extinguishers charged and mounted throughout the facility, serviced on 2/26/2024. LPA reviewed the facility's emergency drill evaluation report, which noted the last earthquake drill was conducted on 4/14/2024 and fire drill on 3/13/2024. Licensee Navarro tested the smoke alarm/carbon monoxide detector and LPA observed it was operational. LPA reviewed the Record of Client's/Resident's Safeguarded Cash Resources (LIC405) for the facility's current clients and did not observe any discrepancies.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Licensee Navarro.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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 1