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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881396
Report Date: 03/30/2023
Date Signed: 03/30/2023 10:58:33 AM

Document Has Been Signed on 03/30/2023 10:58 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:LOVEABLE HOME CARE FOR DISABLED ADULTS & CHILDRENFACILITY NUMBER:
331881396
ADMINISTRATOR:SEYMORE, TONISHAFACILITY TYPE:
735
ADDRESS:1235 JUSTICE PLACETELEPHONE:
(714) 341-4542
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 4CENSUS: 0DATE:
03/30/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Applicant, Tonisha SeymporeTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Janira Arreola, conducted an announced visit for the purpose of conducting the prelicensing inspection on 3/30/2023 at 9:10 a.m. LPA met with applicant Tonisha Seymore for the visit. The applicant is seeking an initial application for an adult residential home with a capacity for (4) residents, ages 18 to 59.

LPA conducted a walk through of the interior and exterior of the facility. The home is a (4) bedroom and (3) bathroom, two story home with attached garage. The fire clearance conducted on 12/19/2022 by Hemet Fire Department was approved the home for (4) ambulatory clients. The client bedrooms were observed to had the appropriate linens, furniture such as bed, dresser, closet space, light, night stand, chair, hygiene items, towels, hamper, and trashcan. The home has extra linens and bath towels in facility closets. First aid kit was locked in locked medication cabinet where resident medications will be stored. Emergency supplies were observed in hallway closet down stairs, as well as cleaning supplies. The facility kitchen has enough pots and pans, cooking utensils, plates and cups for (4) clients. The kitchen had the appropriate food items. LPA observed the bathrooms in the facility to have hand hygiene supplies. The laundry room was observed be functional, and the facility possesses cleaning supplies to conduct regular cleaning of the facility. The smoke alarms and carbon monoxide detectors were found in working condition. The dining room has enough seating for (4) residents, and the outdoor space has enough seating for (4) residents along with umbrella for shade. LPA observed the home has activities for clients to engage in. The hot water temperature was recorded in the kitchen sink at 114F, and the land line was observed to be operational (951 260-5067). No bodies of water or firearms are being kept in the facility. Kitchen knifes will be kept locked with the in the kitchen.

LPA observed the facility restrooms did not have grab bars for clients. The LPA observed the applicant order these items and noted a date of arrival on technical advisory note.

Component III orientation was conducted during the visit with the applicant of the facility. An exit interview was conducted were this report was reviewed and provided to the applicant, Tonisha Seymore.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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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