331881384-7-8-2024-18-AS-YDEO-D6YQNN-20240708121925

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881384
Report Date: 07/08/2024
Date Signed: 07/08/2024 12:19:42 PM

Document Has Been Signed on 07/08/2024 12:19 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:	LEGACY OF HEMET 2, THE		FACILITY NUMBER:	331881384
ADMINISTRATOR/ DIRECTOR:	HYLAND, KATHLEEN		FACILITY TYPE:	740
ADDRESS:	330 S SAN JACINTO ST		TELEPHONE:	(951) 765-1840
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY: 14		CENSUS: 11	DATE:	07/08/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Kay Hyland, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:00 AM, LPA met with Kathleen Hyland. An initial application for Change of Ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 5/3/2024 for a total capacity of fourteen (14); ten (10) non-ambulatory and four (4) bedridden residents. Fire clearance was granted on 05/23/2024. LPA Delgado observed the following: Structure: Facility was a one-story building with two (2) additional structures, thirteen (13) resident bedrooms, eight (8) resident bathrooms, living room, dining area and kitchen. There is no garage; one structure for food storage, personal hygiene storage and second structure is the laundry room and one (1) resident shared room. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control the main building. Bedrooms: Each resident bedroom #101, #102, #103, #104, #105, #108, #109, #110, #111 and #112 will accommodate any non-ambulatory resident, bedrooms #106, #107 and #400 A&B will accommodate bedridden residents. 12 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting. All resident rooms are furnished with a TV. (CONTINUED ON LIC 809C)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LEGACY OF HEMET 2, THE	FACILITY NUMBER: 331881384
	VISIT DATE: 07/08/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Continued from Page 1)

Bathrooms:
The eight (8) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:15 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 121. degrees Fahrenheit with warning labels.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked cabinet located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located in a separate structure. Laundry detergents and cleaning supplies were observed in separate structure away from residents.
Living/Family room:
There was a living room with seating for clients and a TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in the personal hygiene structure.
Yards/Outside:
Patio table and chairs were observed in the outdoor area. There was a gate on the North side with a self-latching lock. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted at all exits. Obudsman poster and Let-Us-No poster observed.

(Continued on Page 3)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LEGACY OF HEMET 2, THE	FACILITY NUMBER: 331881384
	VISIT DATE: 07/08/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Continued from Page 2)

General items:
Five (5) fire extinguishers were charged and located in the kitchen, hallway, 400 structure, break room and laundry room. Three (3) smoke alarms and four (4) carbon monoxide detectors were tested and were observed to be in working order except for one (1) carbon monoxide detector in 400 structure. Three (3) structures are maintained by Security Signal Devices monitors the alarm panel and SBRC Fire Protection that provide fire protection and life safety services for the fire sprinklers and other services. Client records will be stored in a locked cabinet in the Office. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply and 72-hour emergency food supply was observed. Component III will be completed on July 25, 2024 at Riverside RO. There are no firearms stored and no bodies of water observed.

Pre-Licensing is incomplete and the following corrections to be resolved by 8/05/2024:

obtain new flooring
obtain door alarms for 400 structure, room #106, #107
obtain keylock for cleaning supplies under kitchen sink
obtain cover phone line
obtain paper towel holder
organized overflow of medications
repair carbon monoxide detector in 400 structure
repair cabinets doors inside the kitchen
repair exterior window screen for 400 structure
repair broken drawer in laundry room
repair base shelf under kitchen sink
(Continued on Page 3)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LEGACY OF HEMET 2, THE	FACILITY NUMBER: 331881384
	VISIT DATE: 07/08/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Continued from Page 3)

replace dressers in 400 structure
replace ceiling fan light bulb for room #111
replace broken window blinds
replace fan exhaust screen for stove
remove missing toilet paper brackets
remove missing towel bar brackets
remove bottom latch on exit door
set-up room for second resident in 400 structure

An exit interview was conducted with Kathleen Hyland and a copy of this report was given.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4