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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881357
Report Date: 08/12/2024
Date Signed: 08/12/2024 04:43:05 PM


Document Has Been Signed on 08/12/2024 04:43 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:ST. JEANNE CARE HOME LLCFACILITY NUMBER:
331881357
ADMINISTRATOR:DERAMAS, MIRAFEFACILITY TYPE:
740
ADDRESS:10225 BONITA AVETELEPHONE:
(707) 704-4400
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 5DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:Mirafe Deramas, AdministratorTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection at the facility. The LPA was allowed entrance into the facility and met with Administrator, Mirafe Deramas. The LPA informed the Administrator of the purpose for the visit. The inspection included the following:

Physical Plant: The facility consists of four (4) resident bedrooms, two (2) bathrooms, storage areas, a kitchen and dinning area, one (1) living room/office space, and a patio and yard with sufficient seating and space for activities. There are two additional other buildings on the property where staff reside and a laundry area. There are no bodies of water located on the property. According to Administrator Deramas, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. The carbon monoxide and smoke detectors were tested and observed to be in operating condition. The home was kept clean and free of any odors.

Food Service: There is a minimum of 2 days supply of perishable foods and 1 week's supply of non-perishable foods available. Sufficient dinning supplies were available for residents in care. A variety of food was available.

Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Staff training included medication training, restricted healthcare training hospice training, personal rights training, and suspected abuse training. Resident records had required documentation; such as admission agreements, medical assessments, written records of care (appraisal/needs and service plans), and pre-placement appraisals. There is a disaster and mass casualty
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: ST. JEANNE CARE HOME LLC
FACILITY NUMBER: 331881357
VISIT DATE: 08/12/2024
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plan in place. Proof of emergency drills was observed on file. All records were observed to be well organized and safely secured. The facility was not operating beyond the conditions specified on the license. The facility currently has an approved Hospice Waiver for six (6) residents and there is currently one residents in care receiving hospice services.

Medication Review: The LPA inspected resident medications. Medications were observed to be well organized, appropriately labeled and inaccessible to unauthorized individuals.

An exit interview was conducted with Administrator Deramas in which this report was reviewed and a copy was provided. No citations were issued during this visit.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC809 (FAS) - (06/04)
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