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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881322
Report Date: 04/19/2024
Date Signed: 04/19/2024 10:57:06 AM


Document Has Been Signed on 04/19/2024 10:57 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:DELICARE I HEALTH SERVICES, INCFACILITY NUMBER:
331881322
ADMINISTRATOR:AWAD, SAMEHFACILITY TYPE:
740
ADDRESS:27143 SETTLEMENT STREETTELEPHONE:
(909) 559-7200
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY:6CENSUS: 5DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Sameh AwadTIME COMPLETED:
11:00 AM
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On 4/19/2024, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to conduct an annual required inspection. LPA was greeted and granted entry by Caregiver, Eloisa Santiago who was informed of the purpose of the visit. Licensee, Sameh Awad arrived during the visit. During today's visit, there was five (5) residents and two (2) staff present.

The facility has a fire clearance for six (6) non-ambulatory elderly residents, of which one (1) may be bedridden. The facility also has a hospice waiver for three (3) residents and LPA was informed none of the current residents are receiving hospice services. LPA toured the facility's interior and exterior with Caregiver Santiago. LPA observed the facility is made up of a one-story home with five (5) resident bedrooms, three (3) full bathrooms, a kitchen, dining room, living room, laundry room, staff office and attached garage. Indoor and outdoor passageways are free of obstruction. LPA observed the facility has more than a 2-day supply of perishable foods and 7-day supply of non-perishable foods. LPA also observed emergency food and water stored in the garage. Caregiver Santiago tested one of the smoke alarms/carbon monoxide detectors and LPA found it to be operational. LPA observed charged fire extinguishers mounted throughout the facility. The living room fireplace has an appropriate screen to make it inaccessible for residents in care. Medication is secured in two (2) kitchen cabinets. Disinfectants, cleaning solutions, and detergents are secured in the locked laundry room. The facility has a closet with additional linen, towels and comforters available for the residents. LPA reviewed random staff and resident files. Resident files reviewed have signed physician reports and admission agreemenst. Staff files had a criminal record clearance and valid first aid certification. Complaint procedures, Long Term Care Ombudsman information, and facility sketches are posted throughout the facility. The facility does not safeguard the residents' cash resources. 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 Licensee Awad.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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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