<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881388
Report Date: 03/06/2024
Date Signed: 03/06/2024 04:51:53 PM

Document Has Been Signed on 03/06/2024 04:51 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 AC/SC, 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: 3DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Latasha Stokes, AdministratorTIME COMPLETED:
04:50 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) Jacqueline Shaw Ross, conducted unannounced visit for the purpose of a required annual inspection. LPA was greeted at the door by Keihnan Paden, Careprovider and the purpose of the visit was explained. Administrator, Latasha Stokes arrived shortly. The facility is licensed to care for (4) residents who are developmentally disabled, ages 18 to 59. A tour of the facility was conducted inside and outside.

The home is a (5) bedroom and (3) bathroom, one story home with attached garage. Bedrooms 1,2,3 and 4 are for the residents. Bedroom 5 is designated for staff use only. The resident bedrooms were observed to be in good condition with the required furnishings. Extra linens and bath towels are located in the hallway closet. First aid kit was locked in the facility bathrooms and hallway closet. Medications and sharp objects are stored in a locked utility closet in the facility dining area. The cleaning items are kept locked in the facility garage.

Kitchen/Food Service: LPA observed the entire kitchen, food is stored properly and dishes are clean and in good condition. There is a sufficient supply of perishable and non-perishable foods. Area was observed to be clean and functional.
Care & Supervision: Facility has sufficient care staff employed.

Administration: Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility. Drills are conducted monthly.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: E.X.C.E.L II HOUSE, THE
FACILITY NUMBER: 331881388
VISIT DATE: 03/06/2024
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
Record Review and Client/Staff Files: LPA reviewed current staff and all staff have has Criminal Background Clearance, current CPR/First Aid certification, and trainings are current. Client records were reviewed and contained required documents. IPP and Physician reports are current. LPA reviewed P&I logs, records are balanced. P&I funds are kept separately from facility funds.

Medication Review: LPA reviewed medication and medication log. Residents' medications are being dispensed according to physician's orders.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted and a copy of this report was provided to Administrator, Latasha Stokes.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2