331881343-11-22-2023-18-AS-CNWE-CXTNWY-20231122095018

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881343
Report Date: 11/22/2023
Date Signed: 11/22/2023 09:50:26 AM

Document Has Been Signed on 11/22/2023 09:50 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:	IANESSA FAMILY HOME		FACILITY NUMBER:	331881343
ADMINISTRATOR:	RAMIREZ, JAIRO A.		FACILITY TYPE:	735
ADDRESS:	25931 FIGWOOD WAY		TELEPHONE:	(626) 434-9054
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY: 4		CENSUS: 0	DATE:	11/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Ian Marlon Jaestin Ramirez, Co-Administrator		TIME COMPLETED:	09:55 AM

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On 11/22/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Housekeeper, Alma Garma Marantan. LPA met with Co-Administrator, Ian Marlon Jaestin Ramirez who was informed of the purpose of visit. At the time of visit there was zero #0 staff and zero #0 residents present. Jaestin informed LPA that facility haven’t admitted any client. LPA toured the facility inside and out with Alma Garma Marantan.

Tour included:

Kitchen; LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the approved capacity. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen drawer, available only to authorized individuals. Fridge, freezer, and all need appliances were present and shown to be in working condition and clean.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 68 degrees Fahrenheit.

Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medications; Medications will be stored in a locked medication cabinet. The first aid kit was complete.

Continue on LIC809-C

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: IANESSA FAMILY HOME	FACILITY NUMBER: 331881343
	VISIT DATE: 11/22/2023

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Continued from LIC809.

Bathroom; LPA toured hall bathroom and observed bathroom to be clean. There is also a good number of personal toiletries available for the residents. The hot water measured at 115 degrees Fahrenheit.

Bedroom; LPA toured four #4 out of #4 residents bedrooms and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs. Night lights were maintained throughout the facility. Resident #1 bedroom has a private bathroom. LPA observed bathroom to be clean and hot water was measured at 115 degrees Fahrenheit.

Garage; LPA tour the garage and observed garage to be clean and not cluttered. Laundy is located in the garage. Washing machine and dryer are all in good repair and sufficient for the approved capacity. Cleaning supplies are stored away in the garage, inaccessible to clients,

Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gates remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored. Fridge and freezer are large enough to accommodate required perishable foods.

Records: All required postings were posted near the entryway and throughout the facility. Administrator certificated expires on 10/13/2024.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Ian Marlon Jaestin Ramirez.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC809 (FAS) - (06/04)

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