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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881383
Report Date: 01/17/2023
Date Signed: 01/17/2023 03:02:32 PM


Document Has Been Signed on 01/17/2023 03:02 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:GOOD SAMARITAN ELDERLY HOME IIFACILITY NUMBER:
331881383
ADMINISTRATOR:CARREON, MELDY AFACILITY TYPE:
740
ADDRESS:12145 WESTERLY TRAILTELEPHONE:
(951) 259-4762
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:6CENSUS: 4DATE:
01/17/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Applicant, Wendell GarciaTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Janira Arreola, conducted an announced visit for the purpose of conducting the prelicensing visit. LPA met with applicant Wendell Garcia. The applicant is seeking a change of ownership where the applicant is being added to the license. The population served is elderly ages 60 and over with a capacity for (6) residents.

LPA conducted a walk through of the interior and exterior of the facility. The home is a (4) bedroom and (3) bathroom, one story home with an attached garage. The fire clearance conducted by Moreno Valley Fire Department was approved for (6) non-ambulatory residents. LPA observed the clients bedrooms which had the appropriate linens, furniture such as bed, dresser, closet space, light, and chair. The home has extra linens and bath towel in a hallway closet, as well as a first aid kit, and emergency lighting. The facility kitchen has enough pots and pans, cooking utensils, plates and cups for (6) residents. The kitchen had the appropriate food items for the capacity of 6 residents. LPA observed the bathrooms in the facility to have hand hygiene supplies. The laundry room was observed be functional, and the facility possesses cleaning supplies to conduct regular cleaning of the facility. The smoke alarms and carbon monoxide detectors were found in operating condition. The dining room has enough seating for (6) residents, and the outdoor space has enough seating for 6 residents with a shaded area. The hot water temperature was recorded in the kitchen sink at 105F, and the land line was observed to be operational.

No bodies of water or firearms are being kept in the facility. Kitchen knifes will be kept locked with the medications in a locked in facility kitchen.

Component III orientation was conducted during the visit with the applicant. An exit interview was conducted were this report was reviewed and provided to the applicant, Wendell Garcia.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
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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