331881383-1-5-2024-18-AS-CNWE-CZ7V3V-20240105150523

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881383
Report Date: 01/05/2024
Date Signed: 01/05/2024 03:05:28 PM

Document Has Been Signed on 01/05/2024 03:05 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:	GOOD SAMARITAN ELDERLY HOME II		FACILITY NUMBER:	331881383
ADMINISTRATOR:	CARREON, MELDY A		FACILITY TYPE:	740
ADDRESS:	12145 WESTERLY TRAIL		TELEPHONE:	(951) 259-4762
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92557
CAPACITY:	6	CENSUS: 4	DATE:	01/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Meldy Carreon, Licensee		TIME COMPLETED:	03:10 PM

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On 1/5/2024, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by caregiver, Mamichaela Carpio who was informed of the purpose of visit. LPA also met with Licensee, Meldy Carreon who was also informed of the purpose of visit. At the time of visit there were 2 staff and 3 residents present. LPA was informed one resident is at the Day Program. LPA toured the facility inside and out with Mamichaela Carpio and Alma Labagala.

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 census. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen drawer, available only to authorized individuals. Trash cans has tight-fitting lid. 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 70 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 were labeled and stored in separate bins inside of a locked medication cabinet and are distributed according to physician orders. The first aid kit was complete.

Continue on LIC809

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

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: GOOD SAMARITAN ELDERLY HOME II	FACILITY NUMBER: 331881383
	VISIT DATE: 01/05/2024

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Continued from LIC809.

Bathroom: LPA toured hall bathroom and observed bathroom to be clean and equipped with grab bar and non-skid mat. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 106 degrees Fahrenheit.

Bedroom: LPA toured three #3 out of #3 resident bedrooms and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs, and lighting.

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

Laundry: Washing machine and dryer are all in good repair and sufficient for the census. Cleaning supplies are stored away in the laundry room, 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 gates remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents. Fridge and freezer are large enough to accommodate required perishable food.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Three #3 staff and #3 residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expires on 5/30/2024.

Interview: two staff and three resident were interviewed.

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

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC809 (FAS) - (06/04)

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