331881322-4-11-2022-18-AS-JGEE-CDDR3R-20220411124021

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881322
Report Date: 04/11/2022
Date Signed: 04/11/2022 12:40:31 PM

Document Has Been Signed on 04/11/2022 12:40 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:	DELICARE I HEALTH SERVICES, INC		FACILITY NUMBER:	331881322
ADMINISTRATOR:	AWAD, SAMEH		FACILITY TYPE:	740
ADDRESS:	27143 SETTLEMENT STREET		TELEPHONE:	(909) 559-7200
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92585
CAPACITY:	6	CENSUS: 0	DATE:	04/11/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Sameh Awad, Licensee		TIME COMPLETED:	01:05 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	On 04/11/22 Licensing Program Analyst (LPA), Javina George, conducted an announced pre-licensing inspection at the facility. The LPA met with Licensee/Administrator, Sameh Awad. The application is for a Residential Care Facility for the Elderly (RCFE). On 03/09/22 the Menifee Fire department approved the facility for six (6) non-ambulatory residents, of which one (1) may be bedridden and will be in bedroom #5. A tour of the was conducted of the interior and exterior of the facility. The house a single story with, five (5) resident bedrooms, one (1) staff room, three (3) and a half (1/2) bathrooms, kitchen, dining area, laundry room, office, front/backyard area. The walkways of the home were observed to be clutter free with no obstructions present. LPA observed the bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, shower and tubs have grab bars and non-skid mats. The hot water was tested in the three resident bathrooms were measured and ranged from 109 to 112 degrees F. LPA observed food storage and preparation areas and were observed to be clean and sanitary. Refrigerator and freezer are maintained at appropriate temperatures. The kitchen was observed to have dishes, silverware and pots and pans in good repair and enough for the capacity. All appliances are clean and are operable. There is a sufficient supply of linens, towels and personal hygiene items. There is a new first aid kit; all items were present.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

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: DELICARE I HEALTH SERVICES, INC	FACILITY NUMBER: 331881322
	VISIT DATE: 04/11/2022

NARRATIVE

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LPA observed a recreation area with leisure items and activities, which includes a putting green in the backyard for resident use. The facility has taken extra security measures and has a total of 8 security cameras (3) that are located in the dining area, living room and above the front door, (2) in the hallways above the resident bedrooms and (3) cameras outside; backyard, garage and the side walkway.

LPA observed two (2) fire extinguishers. The smoke alarms and carbon monoxide detectors are all connected were tested and are operable. Medications will be locked in a cabinet inside of the kitchen next to the refrigerator. All hazardous materials such as, cleaning and disinfecting supplies, knives, and other sharps are locked and inaccessible to residents. All required forms such as: emergency disaster plan and Covid-19 posters, complaint poster, Administrator Certificate, personal rights, etc. are posted in the hallway outside of the resident bedrooms.

Pre-licensing inspection complete. COMP III was completed immediately following the inspection. The facility is ready to be licensed.

An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee/Administrator Sameh Awad.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

LIC809 (FAS) - (06/04)

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