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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881371
Report Date: 12/19/2023
Date Signed: 12/19/2023 01:26:43 PM

Document Has Been Signed on 12/19/2023 01:26 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: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:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Oluwakemi Alofe, LicenseeTIME COMPLETED:
01:30 PM
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On 12/19/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Licensee, Oluwakemi Alofe who was informed of the purpose of the visit. At the time of visit there was 0 staff and 0 residents present. Licensee stated facility is waiting to be vendorized by IRC. LPA toured the facility inside and out with Oluwakemi Alofe.

Tour included:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the approved capacity. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen cabinet, available only to authorized individuals. Trash cans has tight-fitting lids. Dishwasher is used to clean and sanitize dishes. Fridge, freezer, and all need appliances were present and shown to be in working condition and clean.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 72 degrees Fahrenheit.



Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medication: Medications will be stored in separate bins inside of a locked medication cabinet. The first aid kit was complete.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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: PROVIDENCE BASE CENTER INC.
FACILITY NUMBER: 331881371
VISIT DATE: 12/19/2023
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Bathroom: LPA toured hall bathroom and observed bathroom to be clean. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 105 degrees Fahrenheit.

Bedroom: LPA toured four #4 out of #4 resident bedrooms and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility.

Garage: LPA tour the garage and observed garage to be clean.

Laundry: Washing machine and dryer are all in good repair and sufficient for approved capacity. Cleaning supplies will be stored away in the garage, inaccessible to clients.

Backyard: LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gate remain unlocked. No bodies of water were observed.

Records: All required postings, including COVID’s postings, were posted near the entryway and throughout the facility.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Oluwakemi Alofe.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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