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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881371
Report Date: 12/06/2022
Date Signed: 12/06/2022 12:53:53 PM

Document Has Been Signed on 12/06/2022 12:53 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PROVIDENCE BASE CENTER INC.FACILITY NUMBER:
331881371
ADMINISTRATOR:ALOFE, OLUWAKEMI TFACILITY TYPE:
735
ADDRESS:27962 CALLE TALAVERATELEPHONE:
(951) 679-3499
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY: 4CENSUS: 0DATE:
12/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:ADMINISTRATOR, OLUWAKEMI T. ALOFE.TIME COMPLETED:
01:00 PM
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On December 06, 2022, Licensing Program Analyst (LPA), Venus Mixson conducted a scheduled visit to complete a Pre-licensing inspection. LPA Mixson was greeted and granted entry by Administrator, Oluwakemin Alofe and toured the facility inside and out.

The facility is a single story home with five bedrooms, two bathrooms, a dinning area, Kitchen, laundry room and two car garage. LPA Mixson observed sufficient activities, and the overall facility to be in clean condition with a comfortable temperature through central heating and air conditioner.
LPA Mixson observed passageways to be free from obstruction. Water temperature was tested and found to be within regulation limitations. LPA observed smoke and carbon monoxide combination detectors in working condition, fire extinguisher charged. The Menifee Fire Department gave the all clear on September 13, 2022, and approved the facility for 4 ambulatory, 0 non-ambulatory, and 0 bedridden. The area for medications were centrally stored and locked inside a medication file cabinet. The facility is equipped with lights in the passages, and stocked with emergency night lights throughout the facility. All cleaning supplies are locked inside a cabinet the garage. The sharp objects are locked in a kitchen drawer. The facility land line number is 951-679-3499, was dialed by Administrator and is operable. Emergency phones were posted by telephone. No obstructions outside facility and no bodies of water.

An exit interview was conducted and a copy of this report was reviewed and given to the Administrator. COMP III reviewed.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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