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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881388
Report Date: 02/07/2023
Date Signed: 02/07/2023 03:25:43 PM


Document Has Been Signed on 02/07/2023 03:25 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:E.X.C.E.L II HOUSE, THEFACILITY NUMBER:
331881388
ADMINISTRATOR:STOKES, LATASHA MONIQUEFACILITY TYPE:
735
ADDRESS:27521 BLUE TOPAZ DRIVETELEPHONE:
(951) 602-0801
CITY:ROMOLANDSTATE: CAZIP CODE:
92585
CAPACITY:4CENSUS: 0DATE:
02/07/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Applicant, Latasha StokesTIME COMPLETED:
03:40 PM
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Licensing Program Analysts (LPA) Janira Arreola and Jacqueline Shaw Ross, conducted an announced visit for the purpose of conducting the prelicensing inspection on 2/7/2023 at 1:47 p.m. LPAs met with applicant Latasha Stokes and Glen Walls for the visit. The applicant is seeking an initial application for an residential care facility for the developmentally disabled with a capacity for (4) residents, ages 18 to 59.

LPAs conducted a walk through of the interior and exterior of the facility. The home is a (5) bedroom and (3) bathroom, one story home with attached garage. Bedrooms 1,2,3 and 4 will be for non-ambulatory residents. Bedroom 5 will be for staff use only. The fire clearance was conducted on 12/05/2022 by Riverside County Fire Department. The resident bedrooms were observed to had the appropriate linens, furniture such as bed, dresser, closet space, light, night stand and chair. The home has extra linens and bath towels in the hallway closet. First aid kit was locked in the facility bathrooms and hallway closet. Medications and sharp objects will be kept in locked utility closet in the facility dining area. The cleaners will be kept locked in the facility garage. The facility kitchen has enough pots and pans, cooking utensils, plates and cups for (4) Residents. The kitchen had the appropriate food items. LPA observed the bathrooms in the facility to have hand hygiene supplies, and personal care items for future residents. 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 working condition. The dining room has enough seating for (4) residents, and the outdoor space has enough seating for (4) residents. LPA observed the home has activities for clients to engage in. The hot water temperature was recorded in the kitchen sink at 111.1F, and the land line was observed to be operational (951 878 7405). No bodies of water or firearms are being kept in the facility. The residents P&I will be kept in a locked cabinet in the living room along with the residents and staff records.

Component III orientation was conducted during the visit with the applicant of the facility. An exit interview was conducted were this report was reviewed and provided to the applicants, Latasha Stokes and Glen Walls.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
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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