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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881352
Report Date: 11/29/2023
Date Signed: 11/29/2023 03:26:53 PM

Document Has Been Signed on 11/29/2023 03:26 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:ALMONDS AT TANGERINE AVENUE INCFACILITY NUMBER:
331881352
ADMINISTRATOR:JIMENA, MARLITAFACILITY TYPE:
735
ADDRESS:5475 TANGERINE AVETELEPHONE:
(562) 569-8115
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 6CENSUS: 0DATE:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Licensee, Raymund AlmendaresTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Licensee, Raymund Almendares , who was informed of the purpose of the visit. At time of visit there were (0) clients and (3) staff present.

The facility is a two story home with (6) bedrooms and (3) and half bathrooms with attached garage. Two of the bedrooms are used as staff rooms. The facility does not have a pool or fire arms are kept at the facility. The facility is adult residential home and the clients served are adults between the ages of 18-59 years of age. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Infection Control: LPA observed the hand washing stations had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility.

Physical Plant: LPA observed what will be used as client bedrooms and staff bedrooms. Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards and contained outdoor furniture and shaded area for clients. 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 113.5F.

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: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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: ALMONDS AT TANGERINE AVENUE INC
FACILITY NUMBER: 331881352
VISIT DATE: 11/29/2023
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Record Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid.

Health Related Services/ Incidental Medical Services: No medication is currently stored, area designated for medication was observed.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. Facility has not yet practiced a drill, technical advisory note was documented reminding licensee of requirements. LPA observed all facility exits were clear from obstructions.

No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Licensee, Raymund Almendares.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
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