331881368-5-24-2023-18-AS-CNWE-CS5RZ6-20230524132726

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881368
Report Date: 05/24/2023
Date Signed: 05/24/2023 01:27:32 PM

Document Has Been Signed on 05/24/2023 01:27 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:	LEGACY OF HEMET 1, THE		FACILITY NUMBER:	331881368
ADMINISTRATOR:	KELLOGG, MICHELLE		FACILITY TYPE:	740
ADDRESS:	320 S SAN JACINTO ST		TELEPHONE:	(951) 765-1840
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	16	CENSUS: 13	DATE:	05/24/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Michelle Kellogg, Applicant		TIME COMPLETED:	01:35 PM

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On 5/24/2023, Licensing Program Analyst (LPA), Chinwe Nwogene conducted an announced pre-licensing inspection at the facility. LPA Nwogene met with Applicant, Michelle Kellogg and Administrator, Kathline Hyland. LPA toured the facility inside and out with Michelle and Kathline. There are currently thirteen (13) residents in care due to a change of ownership.

Application: The application is for a Residential Care Facility for the Elderly. The fire clearance has been granted for five (5) ambulatory resident, eight (8) non-ambulatory residents, and three (3) bedridden residents.

Buildings and Grounds: The facility is composed with Livingroom and dining room combination, kitchen, fourteen (14) clients bedrooms, restrooms, laundry room, and backyard. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Michelle, there are no weapons stored in the home. Rooms, furniture, beds, mattresses are all in good repair. The bedrooms are furnished and privacy is available. The dining and living room areas/furniture are clutter free and in good condition. Bathroom was observed to have grab bar, non-slip mat and textured floor. The hot water was tested and measured at 129 degrees Fahrenheit which is above regulatory limit. Outdoor areas had sufficient room for activities. Central heating and air conditioning system installed with a central panel located in hallway to control entire house.

Storage and Supplies: Medications will be stored in a locked moving medication cart located in the hallway, inaccessible to any unauthorized individuals. Secured areas are available for facility files and resident files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away in a locked closet, inaccessible to clients, washing machine and dryer are all in good repair and sufficient for the requested capacity. A Fire extinguisher was available and fully charged.

CONTINUE ON LIC809-C

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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: LEGACY OF HEMET 1, THE	FACILITY NUMBER: 331881368
	VISIT DATE: 05/24/2023

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CONTINUED FROM LIC809

Activities: Inside and outside, there are areas for residents to use for their leisure. Backyard is in good condition. Facility has a gazebo which provides shade over the outside table and chairs. Activity supplies are present inside the home, including television, magazines, and games.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps will be stored in a locked kitchen cabinet, available only to authorized individuals. Trash cans has tight-fitting lid. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 32 degrees Fahrenheit and Freezer was measures at 0 degrees Fahrenheit.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E), Covid-19 posters, Visitors Policy, Personal Rights, rights of resident council, a Facility Sketch (LIC 999), Labor Law Information, and Complaint Information.

Missing Item

Adjusted water temperature (105-120)

LPA informed Michelle to contact Riverside Regional Office to complete the Component III. Once Component III has been completed and proof of the Adjusted water temperature has been received, LPA Nwogene will inform the Centralized Applications Bureau (CAB) that the home is ready for licensure and Applicant will be notified of the license approval.

An exit interview was conducted were this report was discussed with and provided to Michelle Kellogg.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

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