331881342-8-12-2022-18-AS-YDEO-CH8KWP-20220812081547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881342
Report Date: 07/27/2022
Date Signed: 08/12/2022 08:15:53 AM

Document Has Been Signed on 08/12/2022 08:15 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	NOVASIR CARE SERVICES		FACILITY NUMBER:	331881342
ADMINISTRATOR:	DAVIS, ASHLEY		FACILITY TYPE:	735
ADDRESS:	27565 BLOOMING VISTA WAY		TELEPHONE:	(310) 462-4240
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92584
CAPACITY: 4		CENSUS: 0	DATE:	07/27/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Ashley Davis, Licensee & Administrator		TIME COMPLETED:	03:15 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	Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 1:15 PM, LPA met with Licensee/Administrator Ashely Davis. An initial application to operate a Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 5/23/2022 for a total capacity of four (4) non-ambulatory and zero (0) bedridden residents. Fire clearance was granted on 5/26/2022. LPA Delgado observed the following: Structure: Facility was a one-story house with four (4) resident bedrooms, two (2) resident bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the living area to control entire house. Bedrooms: Each resident bedroom #1, #2, #3 and #4 will accommodate any non-ambulatory resident. 4 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bathrooms: The two (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of toilet paper, and soap. At 2:15 PM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 106.3 degrees Fahrenheit. Kitchen/Laundry: An adequate supply of plastic dishes, plastic cups, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. (CONTINUED ON LIC 809C)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: NOVASIR CARE SERVICES	FACILITY NUMBER: 331881342
	VISIT DATE: 07/27/2022

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
26
27
28
29
30
31
32

(CONTINUED FROM LIC 809)
and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the house. Laundry detergents and cleaning supplies were not observed but will be in laundry room away from residents.
Living/Family room:
There was a living/family room with for all clients and TV.
Linens and Hygiene Supplies:
There was not adequate supply of linens observed but will be stored in the Laundry room on shelving.
Yards/Outside:
Patio table and patio sofas were observed in the backyard with two umbrellas. There was a gate on the East side of the property with a self-latching from the exterior doors. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Emergency phone numbers, Exit Plan and Facility sketch were observed posted in the kitchen. Let-Us-No poster observed.
General items:
One (1) fire extinguisher were charged and located in the kitchen. Seven (7) smoke alarms combined with carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the Family room. First Aid kit with required components, and locked area for medication storage was observed. LPA did not observed a facility phone. Emergency water supply was not sufficient and the required 72-hour emergency food supply was not observed. Component III was completed on this day as well.
(CONTINUED ON LIC 809 C)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: NOVASIR CARE SERVICES	FACILITY NUMBER: 331881342
	VISIT DATE: 07/27/2022

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
26
27
28
29
30
31
32

(CONTINUED FROM LIC 809 C)

Pre-Licensing is incomplete and the following corrections to be resolved by 7/28/2022:

obtain 72-hour emergency food supply
obtain additional emergency water
obtain and post visiting policy
obtain 30-Days of PPE supplies
obtain small appliances for kitchen
obtain additional cleaning supplies
obtain additional cooking utensils
obtain emergency lightning for resident rooms
obtain and post signage regarding COVID-19 Infection Control throughout the facility and bathrooms
obtain temperature, signs and symptoms logs for Staff, Residents and visitors
obtain screening area for Infection Control guidelines
obtain paper towels and placed near sinks on stand or dispenser
obtain a lock for laundry room door
obtain additional linen for resident beds
obtain a telephone
obtain a sample menu
obtain night light for passage ways

An exit interview was conducted, and a copy of this report was given.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3