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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881388
Report Date: 03/11/2025
Date Signed: 03/11/2025 04:29:51 PM

Document Has Been Signed on 03/11/2025 04:29 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:E.X.C.E.L II HOUSE, THEFACILITY NUMBER:
331881388
ADMINISTRATOR/
DIRECTOR:		STOKES, LATASHA MONIQUEFACILITY TYPE:
735
ADDRESS:27521 BLUE TOPAZ DRIVETELEPHONE:
(951) 602-0801
CITY:ROMOLANDSTATE: CAZIP CODE:
92585
CAPACITY: 4CENSUS: 4DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Itumeleng Motau, DSPTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 03/11/25 Licensing Program Analyst (LPA) made an unannounced visit to the facility to conduct a 1 year required inspection Direct Support Professional (DSP) Itumeleng Motau greeted LPA and granted entry. LPA conducted a tour of the interior and exterior areas of the facility. The administrator was unable to come to the facility.
The home is a (5) bedroom and (3) bathroom, garage. (4) Bedrooms are designated for clients and (1) bedroom is designated for the (2) live in caregivers. The facility was observed to be clean and clutter free. LPA observed several activities for client use to encourage socialization. The medications were observed to be locked and in accessible to clients in care. The cleaning items are kept locked in the facility garage, along with PPE supplies.
LPA conducted a review of staff files present at the facility and observed for all staff to have obtained criminal record clearance and to be associated to the facility. Staff also possessed current CPR/First Aid certification, and CEU training. The Administrator Latasha Stokes submitted her application for renewal January 2024. Client records were reviewed and observed for updated Individual Program Plans to be needed for the clients. LPA reviewed Personal and Incidental funds which revealed the logs were not updated. The food supply was observed to be sufficient as there was a 2 day supply of perishable and a 7 day supply of non perishable food items. The combined smoke and carbon monoxide detectors were tested and were observed to be operable.
LPA observed for the facility to be using video surveillance in the common areas (hallways and family room). The emergency disaster drills are being conducted on a monthly basis, the last drill was conducted on 03/07/25. The fire extinguishers are due to be serviced in June 2025. The facility annual licensing fees are due, LPA provided PIN 032636, should the facility operator wish to pay electronically. In addition the governing body was observed to be not good and suspended since January 1993 per a file review conducted. LPA will follow up with Administrator in regards to observations made.
An exit interview and a copy of this report and a copy of this report, and LIC811-confidential names list was reviewed and provided to (DSP) Itumeleng Motau.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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