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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881311
Report Date: 08/30/2024
Date Signed: 08/30/2024 02:06:16 PM

Document Has Been Signed on 08/30/2024 02:06 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:CENTINELLA ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
331881311
ADMINISTRATOR/
DIRECTOR:		BOYER, MARITESFACILITY TYPE:
735
ADDRESS:820 CENTINELLA COURTTELEPHONE:
(951) 658-2350
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 6CENSUS: 5DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Adrian Santos, caregiverTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Seo Jeon made an unannounced visit to the facility to complete the annual inspection. LPA arrived at the facility and met with Adrian Santos, caregiver, and toured the inside and outside of the facility. The facility is approved to serve six (6) adults, ages 18 through 59. Per the caregiver, this facility has 5 clients in care.

The facility is a four (4) bedroom, two (2) bathroom one story home. During the inspection, LPA observed the facility to be clean and in good repair with no pathway obstruction. The residents bedrooms, bathrooms and the facility's kitchen, as well as the common areas were inspected and found to be in compliance. All required postings were posted throughout the facility. The Administrator's certificate expires on 3-6-2025. Per the caregiver there are no known firearms and/or ammunition.

The facility is appropriately furnished. The water temperature was tested and measured at 109.9 degrees Fahrenheit. The facility maintains comfortable temperatures. The smoke alarms and carbon monoxide alarms were tested and found operable. LPA observed one fully charged fire extinguisher with current tag in dining area. The kitchen was observed to be fully stocked with a sufficient amount of food and supplies. Emergency food and water was stored in separate area in the pantry. The knives were stored in a locked drawer in the kitchen. The medications are stored in a locked cabinet in the kitchen. P&I funds are kept locked in a cabinet in the living room area and are kept separate from facility funds. Chemicals and hazardous items are also stored in a locked cabinet.

There are no swimming pool or any body of water at this facility. The backyard was observed to be fully fenced with plenty of shade and is free of hazards.

LPA reviewed (3) staff files and reviewed the facility's staff schedule. All staffs have criminal clearance and updated training along with CPR/First Aid Certification. Three (3) client files were reviewed, and possessed all required paperwork.

Continued on LIC809-C....

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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: CENTINELLA ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 331881311
VISIT DATE: 08/30/2024
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LPA reviewed client medications for two (2) clients and found all medication listed on medication administration log. All required labeling was found to be in place, and all medications were accounted for.

LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility performs quarterly fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. Smoke and carbon monoxide alarms were tested and observed to be in working condition.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.



An exit interview was conducted where a copy of this report was provided to Adrian Santos, caregiver.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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