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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881325
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:05:33 AM

Document Has Been Signed on 06/12/2024 11:05 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:A NANA'S LOVEFACILITY NUMBER:
331881325
ADMINISTRATOR/
DIRECTOR:		KIAMINI KHUMBUZILEFACILITY TYPE:
735
ADDRESS:1403 REEDS WAYTELEPHONE:
(951) 350-0354
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 4CENSUS: 2DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Caregiver, Celemusa SiyayaTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On 6/12/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to conduct an annual required inspection. LPA was greeted and granted entry by Caregiver, Celumusa Siyaya who was informed of the purpose of the visit. Licensee, Kendra Danford was also informed of the purpose of LPA's visit. The facility has a fire clearance for four (4) ambulatory clients and serves adults ages 18 through 59.

During the visit, there was one (1) client and one (1) staff present and LPA was informed one (1) client was at day program. LPA toured the facility with Caregiver Siyaya. During the tour, LPA observed the facility is made up of a one (1) story home with four (4) client bedrooms and two (2) bathrooms along with a kitchen, dining room, living room, staff office and attached garage. LPA toured the kitchen and observed the area to be clean. LPA also observed the facility had a 2-day supply of perishable foods and 7-day of non-perishable food items. Food is stored in a safe and healthful manner. Medications were secured in a cabinet stored near the kitchen. LPA reviewed physical medications for both clients as well as Medication Administration Record and did not discover any discrepancies. Client files reviewed had updated Individual Program Plans and signed admission agreements. Client bedrooms were each furnished with a bed, chair and night stand. Bathrooms have a working toilet and wash basin and the hot water temperature in the bathrooms measured at 116- and 117-degrees Fahrenheit. Staff present have a criminal record clearance, are associated with the facility, and have a valid first aid/CPR and nonviolent crisis intervention certification. Outdoor shaded seating area is available for the clients. There are no bodies of water on the premises. Indoor and outdoor passageways are free of obstruction. LPA observed charged fire extinguishers mounted throughout the facility, which were serviced on 3/11/2024. The smoke alarm/carbon monoxide detectors were not tested due to one (1) client's hypersensitivity; however, Licensee reported they were tested on 6/4/2024 and found to be operational. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and this report was reviewed with Licensee over the phone and provided to Caregiver Siyaya.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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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