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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881398
Report Date: 01/13/2023
Date Signed: 01/13/2023 09:47:05 AM


Document Has Been Signed on 01/13/2023 09:47 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:VICTORIA HILLS ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
331881398
ADMINISTRATOR:CHOUDRY, SAHERFACILITY TYPE:
740
ADDRESS:6847 HAWARDEN DRTELEPHONE:
(951) 522-1425
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY:6CENSUS: 0DATE:
01/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Applicant Saher ChoudryTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Janira Arreola, conducted an announced visit for the purpose of conducting the prelicensing inspection on 1/13/2023 at 8:33 a.m. LPA met with applicant Saher Choudry for the visit. The applicant is seeking an initial application for an residential care facility for the elderly with a capacity for (6) residents, ages 60 and up.

LPA conducted a walk through of the interior and exterior of the facility. The home is a (4) bedroom and (2) bathroom, one story home with attached garage. The fire clearance conducted on 12/12/2022 by Riverside City Fire Department was approved the home for (1) ambulatory resident in the master bedroom. LPA observed the room and located the (2) exits that are required. These exits have working alarm systems. The other resident bedrooms were observed to had the appropriate linens, furniture such as bed, dresser, closet space, light, night stand and chair. The home has extra linens and bath towel in the garage which was locked. First aid kit was locked in locked medication cart where resident medications will be stored, as well as emergency flash lights.The facility kitchen has enough pots and pans, cooking utensils, plates and cups for (6) Residents. The kitchen had the appropriate food items. LPA observed the bathrooms in the facility to have hand hygiene supplies, and personal care items for future residents. The laundry room was observed be functional, and the facility possesses cleaning supplies to conduct regular cleaning of the facility. These items are located in the facility locked garage, and under the kitchen sink. The smoke alarms and carbon monoxide detectors were found in working condition. The dining room has enough seating for (6) residents, and the outdoor space has enough seating for (6) residents LPA observed the home has activities for clients to engage in. The hot water temperature was recorded in the kitchen sink at 112.8F, and the land line was observed to be operational (951 215 0672). No bodies of water or firearms are being kept in the facility. Kitchen knifes will be kept locked with the in the kitchen.

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, Saher Choudry.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
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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