331881311-8-2-2022-18-AS-YDEO-CGWQQD-20220802122210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881311
Report Date: 08/02/2022
Date Signed: 08/02/2022 12:22:21 PM

Document Has Been Signed on 08/02/2022 12:22 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:	CENTINELLA ADULT RESIDENTIAL CARE HOME		FACILITY NUMBER:	331881311
ADMINISTRATOR:	AQUINO, LORA MAE D.		FACILITY TYPE:	735
ADDRESS:	820 CENTINELLA COURT		TELEPHONE:	(951) 658-2350
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY: 6		CENSUS: 5	DATE:	08/02/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lora Mae Aquino, Administrator		TIME COMPLETED:	12:30 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	Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:30 AM, LPA met with Administrator Lora Mae Aquino. An initial application for Change of Ownership to operate a Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 5/3/2022 for a total capacity six (6) of two (2) non-ambulatory and four (4) ambulatory residents. Fire clearance was granted on 5/20/2022. LPA Delgado observed the following: Structure: Facility was a one-story house with three (3) resident bedrooms, one (1) resident bathrooms, living room, family room, dining area and kitchen. There was an attached three car garage in the front of the house and a garage in the back that will be use for storage. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the kitchen to control entire house. Bedrooms: Each resident bedroom #1, #2, #3 will accommodate any non-ambulatory and ambulatory residents. 3 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and bedroom #3 had an operable smoke alarm. Bathrooms: The (1) resident bathroom has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:07 AM, LPA tested the water temperatures in the resident bathroom. LPA verified water temperature was measured at 90.8 for sink A, 113 for sink B, shower 85 degrees Fahrenheit. (CONTINUED ON LIC 809-C)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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: CENTINELLA ADULT RESIDENTIAL CARE HOME	FACILITY NUMBER: 331881311
	VISIT DATE: 08/02/2022

NARRATIVE

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(CONTINUED FROM LIC809)

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational but missing a knob. Refrigerator/freezer were in working condition.
and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the garage. Laundry detergents and cleaning supplies were observed in garage away from residents.
Living/Family room:
There was a living/family room with for all clients and TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the resident bathroom.
Yards/Outside:
Four chairs were observed in the backyard; more chairs and patio table with shade are needed. There was a gate on the North east side that needs a self-latching lock with a spring from the exterior doors that needs to be repaired. Some outdoor pathways had obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the kitchen, living room and family room. Let-Us-No poster observed.
General items:
One (1) fire extinguishers were charged and located in the family room. Six (6) smoke alarms and two (2) carbon monoxide detectors were tested and were observed to be in working order except for two (2) in bedrooms #1 and bedroom #2. Client records will be stored in a locked cabinet in the Family room. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply was insufficient and emergency food was low. Component III was completed on this day as well.

(CONTINUE ON LIC 809-C

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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: CENTINELLA ADULT RESIDENTIAL CARE HOME	FACILITY NUMBER: 331881311
	VISIT DATE: 08/02/2022

NARRATIVE

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(CONTINUE FROM LIC809-C)

Pre-Licensing is incomplete and the following corrections to be resolved by 8/16/2022:

obtain additional 72-hour emergency food supply
obtain additional separate emergency water
obtain and post visiting policy
obtain 30-Days of PPE supplies
obtain licensed plumber to repair leak in resident bathroom and adjust water temperature between 106-120 degrees
obtain patio table with shade and additional seating
obtain fireplace equipment to make inaccessible
obtain night light for hallways
obtain and post Infection Control signage throughout the facility
remove debris in the backyard
repair smoke detector in Bedroom #1 and #2
replace knob for stove
relace trash can in resident bathroom with lid
replace NE gate door knob and spring
relocate client files to secure cabinet
relocate paper towel dispenser in resident bathroom
relocate beds for residents for 6 foot distance
Submit updated plan for insects in kitchen

An exit interview was conducted, and a copy of this report was given.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC809 (FAS) - (06/04)

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