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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881301
Report Date: 06/23/2022
Date Signed: 06/23/2022 12:41:48 PM


Document Has Been Signed on 06/23/2022 12:41 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:A DRESSAGE HOME CAREFACILITY NUMBER:
331881301
ADMINISTRATOR:LABASTIDA, ROMEO G.FACILITY TYPE:
740
ADDRESS:12029 DRESSAGE LANETELEPHONE:
(714) 206-1964
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: DATE:
06/23/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Adminsitrator- Romeo LabastidaTIME COMPLETED:
12:45 PM
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On 06/23/2022 Licensing Program Analyst (LPA) Janira Arreola conducted an announced visit for the purpose of a pre-licensing inspection. LPA met and was granted entry by Licensee, Romeo Labastida who was informed of the purpose of the visit. 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 over. LPA observed Fire Clearance dated (1/21/2022) was approved for 1 bedridden resident which was not noted on the comments on the facility profile. LPA will reach out to the assigned 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 is a single story 6 bedroom and 2 bathroom home with an attached garage. Bedrooms 1, 2, 3, and 4, are being used for residents and bedrooms 5 and 6 are being used for staff. Each bathroom had soap, paper towels, anti-slip mats, hand washing signs and sturdy grab bars. All 6 bedrooms have a night stand, lamp, bed, and closet space. LPA observed emergency lighting in hallways and bedrooms. LPA observed alarm system on all doors leading to the exterior of the home to ensure resident's safety. All (5) fire extinguishers were up to date and all fire alarms and Carbon Monoxide alarms were in good working condition. LPA observed locked closet in hallway where medications will be kept, and locked areas were cleaning supplies and sharp objects will be kept. LPA observed enough personal hygiene supplies including deodorant, shampoo, tooth brushes, toothpaste and body wash. The dining area has more than the needed 6 chairs, and the outdoor seating area also had 6 chairs available under a shaded area. LPA tested the hot water temperature which was 107 degree Fahrenheit. LPA observed a 2 day supply of non-perishable foods, sufficient 7-day supply of perishable foods, and enough plates, cups, pots, pans and silverware for 6 residents.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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: A DRESSAGE HOME CARE
FACILITY NUMBER: 331881301
VISIT DATE: 06/23/2022
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LPA observed a storage room in the garage of the facility that was not noted on the submitted facility sketch. Building permits were not available at the facility when requested. For this reason, the facility is not cleared for licensure at the time of this visit. The applicant must submit proof of correction to LPA in order to be cleared for licensure.

An exit interview was conducted where this report was reviewed and provided to Licensee Romeo Labastida.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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