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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881301
Report Date: 07/10/2024
Date Signed: 07/10/2024 03:33:28 PM


Document Has Been Signed on 07/10/2024 03:33 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:A DRESSAGE HOME CAREFACILITY NUMBER:
331881301
ADMINISTRATOR:LABASTIDA, ROMEO G.FACILITY TYPE:
740
ADDRESS:12029 DRESSAGE LANETELEPHONE:
7142061964
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 5DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Rosalinda Pangilinan, caregiverTIME COMPLETED:
03:40 PM
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Licensing Program Analysts (LPAs) Seo Jeon and Javina George conducted an unannounced annual required visit on 7-10-2024 at 1:57pm. LPA was granted entry by Caregiver Rosa Panglinan. The Administrator Romeo Labastida arrived shortly and was informed of the purpose of today's visit. At the time of the visit there was (2) staff and (5) residents present. The facility is licensed to serve age range 60 and over, approved for (6) non ambulatory of which 1 may be bedridden. The facility also has an approved hospice waiver for (6). The facility currently has (1) resident receiving hospice services and does not have a resident that is bedridden.

The facility is a one story facility with (6) bedrooms, of which 1 is for a live in caregiver and (2) bathrooms. LPA conducted a tour of the interior and exterior of the facility and observed the following:

The facility has an approved infection control plan on file. The facility was observed to be clean and clutter free. The passage ways were observed free from obstruction. There are no pools or bodies of water on the premises, or no known guns or ammunition on the grounds. The hot water was tested and was found to be within regulatory limits measuring at 105.9 degrees Fahrenheit. The emergency disaster drills are being conducted on a quarterly basis and the last drill was conducted on 4/10/24, and will be conducted by the end of this month for this quarter. The facility has (6) fully charged fire extinguisher with the tags in tact. The smoke and carbon monoxide detectors were tested and found to be operable.



The resident bedrooms had the required furniture such as dressed, bed and adequate lighting. The facility was observed to have adequate food supply as there was a 2 day supply of perishable and a 7 day supply of non-perishable food items.
Records review was conducted of both (3) staff and (3) resident files. The staff files were observed to have the required documentation and all staff present had valid Cardio Pulmonary Resuscitation (CPR) certification.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo JeonTELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
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 2


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: A DRESSAGE HOME CARE
FACILITY NUMBER: 331881301
VISIT DATE: 07/10/2024
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Based on today's inspection no deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.



An exit interview was conducted and a copy of this report was provided to Administrator Romeo Labastida.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo JeonTELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2