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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881393
Report Date: 02/28/2023
Date Signed: 02/28/2023 11:07:17 AM


Document Has Been Signed on 02/28/2023 11:07 AM - 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:INLAND SENIOR MANORFACILITY NUMBER:
331881393
ADMINISTRATOR:PEREZ, MA. TERESAFACILITY TYPE:
740
ADDRESS:25871 SUN CITY BLVDTELEPHONE:
(562) 350-8537
CITY:MENIFEESTATE: CAZIP CODE:
92586
CAPACITY:6CENSUS: 0DATE:
02/28/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:ADMINISTRATOR, TERESA PEREZ.TIME COMPLETED:
11:15 AM
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On February 28, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived for a scheduled visit for the purpose of conducting a pre-licensing inspection. LPA Mixson met with Administrator and toured home inside and outside. The location is a single story home with six bedrooms, three bathrooms, a living room, dinning room, activity room, family room, kitchen, and two car garage with backyard and front yard. The Riverside County Fire Department approved this location for 4 ambulatory, 2 non-ambulatory, and 0 bedridden residents. The home has a first aid kit and manual, the Administrator has received First Aid and CPR training.
LPA Mixson observed where medications will be stored and locked. The home is equipped with lights in the passages, and stocked with emergency night lights throughout the home. The smoke and carbon monoxide detectors were tested and are operable. LPA Mixson observed two fire extinguisher charged and in the green. LPA Mixson observed cleaning supplies locked and inaccessible. The sharp objects are locked in a kitchen drawer, plenty of pots, pans and other kitchen accessories. The facility has some non-perishable food items, as well as, hygiene supplies for residents. All doors, and passageways are clear from obstruction. There were no bodies of water, fire place was covered with screen, and non operational. LPA Mixson observed beds have the required linen and supplies. There was enough clean linen and hygiene items. There was appropriate lighting in each room with night stand, dresser and chair. LPA Mixson observed central heating and air conditioning systems. The Administrator dialed the land line phone number (951)566-5532 and it was operable. Outside/Yards: No obstructions observed, and no ammunition or fire arms. Component III reviewed.
An exit interview was conducted, a copy of this report was provided to Administrator.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023
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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