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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881393
Report Date: 04/15/2024
Date Signed: 04/15/2024 11:00:25 AM


Document Has Been Signed on 04/15/2024 11:00 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
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: 5DATE:
04/15/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee, Teresa PerezTIME COMPLETED:
11:00 AM
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Licensing Program Manager (LPM) Tricia Danielson and Licensing Program Analyst (LPA) Janette Romero met with Licensee, Teresa Perez at the Riverside Adult and Senior Care Regional Office for the purpose of discussing ongoing concerns with the facility.

Below is a summary of what was discussed:

Licensee reported they are working with Assisted Living Waiver Program (ALWP) to find more appropriate placement for Resident 1 (R1). Licensee reported ALWP approved and is providing 1:1 care staff for R1 during the hours of 7:00 p.m. to 7:00 a.m until proper placement is found. Licensee reported the facility has one (1) awake night staff on duty at all times. Licensee confirmed understanding that R1 cannot be discharged from the facility via 51/50 hold.

An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee Perez.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
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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