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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881308
Report Date: 08/19/2022
Date Signed: 08/19/2022 10:19:54 AM

Document Has Been Signed on 08/19/2022 10:19 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:A PLACE OF LOVEFACILITY NUMBER:
331881308
ADMINISTRATOR:MOJICA, FLORENCEFACILITY TYPE:
735
ADDRESS:1360 N PALM AVETELEPHONE:
(310) 592-5338
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 6CENSUS: 0DATE:
08/19/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Florence "Bree" Mojica - ApplicantTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility for the purpose of conducting a Pre-Licensing visit. Analyst met with Applicant Florence "Bree" Mojica and toured the facility. Fire Clearance was granted for six (6) non-ambulatory clients on 5/4/22 by the Hemet Fire Department. The facility is going to apply to be vendorized through Inland Regional Center for developmentally disabled adults ages 18 - 59 once licensed. Home is set-up with living room, family room, kitchen, dining room, three (3) resident bedrooms, 2 restrooms, backyard, and a garage, and laundry room.

Analyst observed required accommodations in residents' bedroom and bathrooms including inspection of beds, mattresses, and closet space. Smoke detectors and carbon monoxide units are all operable, as observed by LPA Colvin when applicants tested them. Common areas such as dining and living rooms were observed to be clean and in good condition.

ADMINISTRATION/MEDICATION: A locked standing cabinet is present in the dining room for record storage, and medications will be locked in a cabinet in the kitchen.

PHYSICAL PLANT: Outside premises were inspected for potential hazards. Cleaning solutions and other hazardous items are stored and locked in the garage. Outside gate was observed to be unlocked for clients' and staff's use in case of emergency as an exit. Exit route from backyard was observed to be free of obstruction. LPA Colvin tested the facility's hot water and observed it to be measuring at 112.4 degrees.

ACTIVITIES: Inside and outside, there are areas for residents to use for their leisure. Backyard is in good condition with outdoor furniture and a shaded area for the residents. Activities inside the home include television, board games, books, and magazines. The Applicant additionally has a space indoors allocated for activities including exercise.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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: A PLACE OF LOVE
FACILITY NUMBER: 331881308
VISIT DATE: 08/19/2022
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FOOD SERVICE: The kitchen area was observed for the ability to serve food and cleanliness. Trash can has tight-fitting lid. Dishes, utensils and glasses are present and in sufficient number for residents and staff. Dishwasher will be used to clean and sanitize dishes. Knives will be kept locked and out of clients' reach for safety purposes, as well as cleaning chemicals. All need appliances were present and shown to be in working condition and clean. Facility has both perishable and non-perishable supply of food to satisfy the 2 day and 7 day requirements.

EMERGENCY EXIT PLAN: Facility has an emergency exit plan in place an posted in plain view at the facility, along with operational smoke detectors and carbon monoxide detectors, as well as multiple fire extinguishers.
Infection Control: LPA Colvin observed the facility to have a symptoms screening station at the front door entrance, which includes thermometer for checking visitors temperature, hand sanitizer, and sign-in log. LPA Colvin additionally observed additional PPE stored at this station, such as face coverings, for visitors if they do not bring their own. Facility has COVID-19 postings at the front of the facility including sign on the door informing that face coverings are to be worn at all times. Sinks are stocked with hand soap and paper towels, and there is a hand washing guide posted on the mirror.

Analyst will inform Centralized Applications Bureau (CAB) about the Pre-Licensing visit and Applicant will be notified of the license approval.

An exit interview was conducted with Applicant Florence "Bree" Mojica and a copy of the report was provided as well as LPA Colvin's business card with contact information.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
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