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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881393
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:00:22 PM


Document Has Been Signed on 03/05/2024 12:00 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: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: 6DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Ma Theresa PerezTIME COMPLETED:
12:00 PM
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On 3/5/2024, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to conduct a required annual inspection at the facility. LPA was greeted and granted entry by Caregiver, Elsie Calapano who was informed of the purpose of the visit. Licensee, Ma. Teresa Perez arrived during the visit.

During today's visit, LPA conducted a tour of the facility's interior and exterior with Caregiver Calapano. During the tour, LPA observed the facility is made up of a one-story home with 5 resident bedrooms, 3 resident bathrooms, a kitchen, dining room and two (2) living rooms. The facility is licensed to care for four (4) ambulatory and two (2) non-ambulatory residents ages 60 and over. The facility also has an approved hospice waiver for six (6) residents and a dementia care plan of operation. During LPA's visit, there was six (6) residents and three (3) staff present. LPA observed residents in their rooms and in common areas of the facility. Licensee tested the smoke alarms/carbon monoxide detectors and LPA found them to be operational. There are two (2) fire extinguishers charged and mounted in the facility, which were serviced on 12/4/2023. LPA observed the facility has a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Resident rooms had the required bedding, furniture and lighting. LPA observed disinfectants and cleaning solutions secured in a bathroom cabinet. Medications are also secured and only accessible to facility staff. Indoor and outdoor passageways are free of obstruction and the physical plant is in good condition.

During today's visit, LPA did not issue any deficiencies. An exit interview was conducted where this report was reviewed and provided to Licensee Perez.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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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