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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881325
Report Date: 06/02/2023
Date Signed: 06/02/2023 12:05:19 PM

Document Has Been Signed on 06/02/2023 12:05 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A NANA'S LOVEFACILITY NUMBER:
331881325
ADMINISTRATOR:KIAMINI KHUMBUZILEFACILITY TYPE:
735
ADDRESS:1403 REEDS WAYTELEPHONE:
(951) 350-0354
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 4CENSUS: 0DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Kayahna WalkerTIME COMPLETED:
09:36 AM
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Licensing Program Analyst (LPA) Cheryl Goodrich and Stephanie Martinez conducted an unannounced annual visit. LPA met with the staff Kayahna Walker at the front door and was granted entry. Administrator and Licensee Kendra Danfords was unable to attend the visit, but attended over the phone. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. Facility is approved for four (4) ambulatory residents. The facility currently has no resident. The facility has never had residents since they have been licensed.
Physical Plant: front entrance, interior and surrounding exterior were clean and in good repair with no pathway obstruction; facility temperature read at 114.2 degrees; there were no bodies of water on premises; there was sufficient lighting and mattress pads in all four of the bedrooms; fire alarm and smoke carbon monoxide detectors were in working order. Facility does not house firearms and/or ammunition on grounds.
Food Services: 7-day non-perishable and 2 day of perishable food supply was observed and all food was properly stored and available.
Medication/Facility Records: Medications cabinet observed with a log and medication log book and inaccessible. Staff responsible for direct care and supervision have current First Aid / CPR training. Their are no residents in care.
Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with staff, Kayahna Walker and a copy of this report was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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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