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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881313
Report Date: 05/03/2024
Date Signed: 05/03/2024 01:41:59 PM

Document Has Been Signed on 05/03/2024 01:41 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TEYRENCE ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
331881313
ADMINISTRATOR/
DIRECTOR:		MANALANG, RUBENFACILITY TYPE:
735
ADDRESS:1821 FITZGERALD AVENUETELEPHONE:
(951) 487-6828
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY: 6CENSUS: 4DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Administrator, Ruben ManalangTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 5/3/2024, Licensing Program Analyst (LPA), Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Administrator, Ruben Manalang. During today's visit, there was two (2) staff present and LPA was informed clients were at day program.

The facility has a fire clearance for six (6) clients of which two (2) may be non-ambulatory. LPA toured the facility's interior and exterior with Administrator Manalang and observed the following:

The facility has charged fire extinguishers mounted throughout the facility that were serviced on 10/16/2023. Administrator Manalang tested one of the smoke alarms/carbon monoxide detectors and LPA found it to be operational. The facility also has emergency food, water and backpacks filled with emergency kits stored in the garage available for the clients. LPA toured the kitchen and observed the facility had a 2-day supply of perishable foods and 7-day supply of non-perishable food items, and knives were secured in a locked kitchen drawer. Medication is secured in a locked closet near the kitchen. Client bedrooms had the required bedding, furniture and lighting. Bathrooms were clean and had toilet paper and towels readily available. The facility has additional comforters, linen and towels available in a hallway closet. LPA reviewed all four (4) clients' files and observed client files have signed admission agreements, updated Individual Program Plans and physician's reports. LPA reviewed two (2) random clients' Medication Administration Records along with their physical medications and did not discover any discrepancies. LPA reviewed the current clients' Record of Client's/Resident's Safeguarded Cash Resources (LIC405) and their physical monies and did not discover any discrepancies. Staff present have a criminal record clearance and a valid first aid and nonviolent crisis intervention certification.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Manalang.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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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