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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881343
Report Date: 11/06/2024
Date Signed: 11/06/2024 04:12:26 PM

Document Has Been Signed on 11/06/2024 04:12 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:IANESSA FAMILY HOMEFACILITY NUMBER:
331881343
ADMINISTRATOR/
DIRECTOR:		RAMIREZ, JAIRO A.FACILITY TYPE:
735
ADDRESS:25931 FIGWOOD WAYTELEPHONE:
(626) 434-9054
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 2DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Administrator, Jairo RamirezTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Jairo Ramirez and Licensee Marlon Ramirez. Two staff and two clients were present during the visit. LPA conducted a walk through, records review, and interviews during the visit.

The facility is a one story home with four bedrooms and two bathrooms for clients. No firearms or pools are kept at the facility. The facility is an adult residential facility serving clients ages 18 to 59.

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility had posted infection control plan and training for staff on infection control measures.



Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 112F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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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: 11/06/2024
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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA reviewed the staff schedule showing adequate staff coverage. Required postings were found in the facility. The listed administrator has a posted and current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed two staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two client files were reviewed which possessed all required documents. Through file review and interview it was found that staff had not been reporting incidents to licensing. No reportable incidents have happened at the facility. LPA documented technical note with licensing contact information to report any future incidents.

Health Related Services/ Incidental Medical Services: All client medication was locked in a cabinet. LPA reviewed client medications for (2) client and found all medication listed on MARS and accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill 10/14/2024, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aide kit.

No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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