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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881342
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:30:11 PM

Document Has Been Signed on 08/30/2023 04:30 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:NOVASIR CARE SERVICESFACILITY NUMBER:
331881342
ADMINISTRATOR:DAVIS, CHRISFACILITY TYPE:
735
ADDRESS:27565 BLOOMING VISTA WAYTELEPHONE:
(310) 462-4240
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 4CENSUS: 2DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Chris Davis, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility for the purpose of an annual inspection. LPA was greeted by Care Provider, Aaliyah Green and explained the purpose of the visit. Administrator Chris Davis arrived shortly. A tour of the facility was conducted inside and out. Present at the facility were two clients and one staff.

The facility is a four (4) bedroom two (2) bathroom one story home. Each client has their own private bedroom and share a bathroom. There is another bedroom reserved for staff and an empty bedroom for new clients.

The facility appears clean and free of odors. Staff present have criminal record clearances and are appropriately associated to the facility. Client bedrooms are clean and appropriately furnished. All smoke and carbon monoxide detectors were tested and found operational. Food supplies are sufficient. Emergency food and water was stored in the garage. Hot water was measured in the client's bathroom and the temperature read 117 degrees Fahrenheit. LPA observed all toxic chemicals and other hazards secured and inaccessible to clients. Medications are centrally stored in a locked cabinet in the kitchen. Furniture in the home is in good repair. Outdoor space is free of hazards.
LPA inspected the staff and client records. Staff files had the required documentation including Background Criminal Clearance, First Aid Certifications and training
documents. The Administrators' certificate expires 10/8/2023. Client files had required documentation including Admissions Agreement, current IPP, and Physicians report. P&I monies are kept in a locked pantry and are kept separately from facility funds. LPA inspected medications and medications appear to be dispensed appropriately according to the physician's orders. The facility is completing emergency drills monthly. Staff and client interviews were conducted.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted and a copy of the report was provided to Administrator Chris Davis.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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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