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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881343
Report Date: 11/03/2022
Date Signed: 11/03/2022 01:29:14 PM

Document Has Been Signed on 11/03/2022 01:29 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:IANESSA FAMILY HOMEFACILITY NUMBER:
331881343
ADMINISTRATOR:RAMIREZ, JAIRO A.FACILITY TYPE:
735
ADDRESS:25931 FIGWOOD WAYTELEPHONE:
(626) 434-9054
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 0DATE:
11/03/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:ADMINISTRATOR, JAIRO RAMIREZ.TIME COMPLETED:
01:45 PM
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On November 03,2022, Licensing Program Analysts (LPA's) Janira Arreola and Venus Mixson conducted a scheduled visit for the purpose of conducting a pre-licensing inspection. LPA's met with Administrator, Jairo Ramirez and were shown the facility inside and outside. Facility is a single story home with (4) bedrooms, (2) bathrooms, a living room, dinning room, kitchen, and two car garage with backyard. On June 08, 2022, the Moreno Valley Fire Department approved the facility for 4 ambulatory residents, 0 non- ambulatory, and 0 bedridden. During today's inspection, LPA's toured the interior and exterior of the facility. The medications were centrally stored and locked inside a medication closet. The facility is equipped with lights in the passages. The facility is also stocked with emergency night lights throughout the facility. The smoke and carbon monoxide detectors were tested and are operable. There was one fire extinguishers observed. LPA's observed locked cleaning supplies. The sharp objects are locked in a kitchen drawer. All doors, and passageways are clear from obstruction. All beds have the required linen and supplies. There was enough clean linen and hygiene items. There was appropriate lighting in each room with night stand and chair. LPAs observed central heating and air conditioning systems. The Administrator dialed the land line phone number (951) 242-7048, and it is operable. Outside/Yards: No obstructions or bodies of water observed on the property. Component III reviewed.
An exit interview was conducted and a copy of this report was provided to Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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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