331881298-5-19-2023-18-AS-CNWE-CRYNFM-20230519102547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881298
Report Date: 05/19/2023
Date Signed: 05/19/2023 10:25:56 AM

Document Has Been Signed on 05/19/2023 10:25 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MERCY OF GOD LLC		FACILITY NUMBER:	331881298
ADMINISTRATOR:	DODO-WILLIAMS, TAYE		FACILITY TYPE:	735
ADDRESS:	13671 REGIS DRIVE		TELEPHONE:	(951) 214-2123
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY: 4		CENSUS: 0	DATE:	05/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Taye Dodo-Williams, Licensee		TIME COMPLETED:	10:35 AM

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On 5/19/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Licensee, Taye Dodo-Williams who was informed of the purpose of visit. At the time of visit there was 0 staff and 0 residents present. Licensee stated since the facility was licensed on 05/03/2022, facility has not had any client and staff. LPA toured the facility inside and out with Taye.

Tour included:

Kitchen; LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the approved capacity. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen cabinet under the sink, available only to authorized individuals. Trash cans has tight-fitting lids. Dishwasher is used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 40 degrees Fahrenheit and Freezer was measures at 0 degrees Fahrenheit.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 70 degrees Fahrenheit.

Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medications; LPA inspected medication cabinet located in the livingroom and observed no medication because there is no client in care. The first aid kit was complete.

Continue on LIC809-C.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MERCY OF GOD LLC	FACILITY NUMBER: 331881298
	VISIT DATE: 05/19/2023

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Continued from LIC-809.

Bathroom; LPA toured hallway bathroom and observed bathrooms to be clean and equipped with grab bar. There is also a good number of personal toiletries available for the residents. The hot water measured at 117 degrees Fahrenheit.

Bedroom; LPA toured four #4 out of #4 residents bedrooms and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Resident #1 bedroom has a private bathroom. LPA observed bathroom to be clean and hot water was measured at 117 degrees Fahrenheit.

Garage; LPA toured the garage and observed garage to be clean.

Laundry; LPA observed the laundry room to be clean. Washing machine and dryer are all in good repair and sufficient for the approved capacity. Cleaning supplies are stored away in the laundry room, inaccessible to clients.

Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gate remain unlocked. No bodies of water were observed.

Food Services: LPA did not observe two days perishable foods because there was no client in care. Licensee stated perishable foods will be available when clients are admitted. LPA observed seven days non-perishable food supply present, and all food was properly stored.

Records: No file review was conducted because facility currently has no client or staff. All required postings were posted near the entryway and throughout the facility. The administrator certificate expires on 6/8/2024.

Interview; No interview was conducted because facility currently has no client or staff.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed with and provided to Taye Dodo-Williams.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC809 (FAS) - (06/04)

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