331881390-3-21-2023-18-AS-YDEO-CQ5UDT-20230321152929

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881390
Report Date: 03/13/2023
Date Signed: 03/21/2023 03:30:14 PM

Document Has Been Signed on 03/21/2023 03:30 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:	DNM RESIDENTIAL CARE HOMES INC		FACILITY NUMBER:	331881390
ADMINISTRATOR:	MILES, WILTON		FACILITY TYPE:	735
ADDRESS:	3077 KALEI		TELEPHONE:	(951) 563-5230
CITY:	PERRIS	STATE: CA	ZIP CODE:	92571
CAPACITY: 4		CENSUS: 0	DATE:	03/13/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Wilton Miles, Administrator		TIME COMPLETED:	12:15 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 Licensee/Administrator Wilton Miles, Naomie Arroyo, House Manager and Don Jobe, Owner. An initial application for Initial Application to operate a Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 1/9/2023 for a total capacity of four (4) ambulatory residents. Fire clearance was granted on 12/28/2022. LPA Delgado observed the following: Structure: Facility was a two-story house with four (4) resident bedrooms, three (3) resident bathrooms, living room, family room, dining area and kitchen. There was an attached two car garage in the front of the house. Heating/Cooling System: Central heating and air conditioning system installed with a panel located in the hallway on the first floor and a panel on the second floor to control entire house. Bedrooms: Each resident bedroom #1, #2, #3 and #4 will accommodate any ambulatory resident, bedroom #5 is Master for Office and common use by residents. 4 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bathrooms: The three (3) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of toilet paper, no paper towels, no handsoap, no lidded trash cans and no handwashing signage observed. At 9:46 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 126.1 degrees Fahrenheit. Shower in hallway second floor water temperature measured at 85 degrees. (CONTINUED ON LIC 809C)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

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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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: DNM RESIDENTIAL CARE HOMES INC	FACILITY NUMBER: 331881390
	VISIT DATE: 03/13/2023

NARRATIVE

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(CONTINUED FROM LIC 809)

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked cabinet 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 on the second floor. Laundry detergents and cleaning supplies were observed in hallway on the second floor inaccessible away from residents.

Living/Family room:
There was a living/family room for all clients and TVs.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the hallway on the second floor of the residence.

Yards/Outside:
Patio table and six chairs were observed in the backyard in shaded area. There was a gate on the South side of the property with a self-latching from the exterior door. All outdoor pathways were free of obstructions. No Pool or bodies of water observed.

Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted throughout the the facility. Resident Rights, Let-Us-No poster, Consumer Grievance procedure and House Rules, and LIC 500 observed.

(Continued on 809-C)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DNM RESIDENTIAL CARE HOMES INC	FACILITY NUMBER: 331881390
	VISIT DATE: 03/13/2023

NARRATIVE

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(Continued from 809-C)
General items:
Two (2) fire extinguishers were charged and located in the kitchen and second floor hallway. Ten (10) smoke alarms and two (2) carbon monoxide detectors were tested and were observed to be in working order. Client records and Staff records will be stored in a locked cabinet in the Master Bedroom . First Aid kits are missing scissors, and locked area for medication storage was observed in closet on the first floor. 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 was observed however the required 72-hour emergency food supply was not sufficient. Component III was completed on this day as well.

Pre-Licensing is incomplete and the following corrections to be resolved by 3/17/2023:
Kitchen and oven needs a deep cleaning
obtain additional 72-hour emergency food supply
obtain 30-Days of PPE supplies
obtain lidded trash cans for all bathrooms and kitchen
obtain scissors for all emergency kits
obtain walkie talkies
obtain paper towels on stands for bathrooms
obtain hand soaps for bathrooms
obtain hand hygiene signage
obtain emergency lightning for resident bedrooms
obtain licensed plumber to adjust water temperatures for all sinks, showers between 105-120 degrees F.
replace 3 light bulbs in kitchen
replace recess light button for living room
replace door knobs on dresser for bedroom #2
remove debris in the backyard
remove bedroom set from Master room
remove outdoor camera

An exit interview was conducted, and a copy of this report was given.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC809 (FAS) - (06/04)

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