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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881420
Report Date: 05/22/2023
Date Signed: 05/22/2023 03:30:41 PM


Document Has Been Signed on 05/22/2023 03:30 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:PENDA HOMES ASSISTED LIVINGFACILITY NUMBER:
331881420
ADMINISTRATOR:KIMINYEI, MILDREDFACILITY TYPE:
740
ADDRESS:26042 WESTRIDGE AVENUETELEPHONE:
(619) 483-6656
CITY:MENIFEESTATE: CAZIP CODE:
92586
CAPACITY:3CENSUS: 0DATE:
05/22/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Applicant Kiminyei MildredTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPAs) Janira Arreola and Sara Martinez, conducted an announced visit for the purpose of conducting the prelicensing inspection on 5/22/2023 at 2:40 p.m. LPA met with applicant Kiminyei Mildred for the visit. The applicant is seeking an initial application for an residential care facility for the elderly with a capacity for (3) residents, ages 60 and up.

LPAs 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 by Menifee Fire Department was approved the home for (1) bedridden resident in bedroom #4. Bedrooms #4 and #3 are licensed with the department. LPA observed the bedroom#4 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. First aid kit was found in living room and resident medications will be kept locked in kitchen. The facility kitchen has enough pots and pans, cooking utensils, plates and cups for (3) Residents. LPAs observed where knifes will be kept locked. 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 and were observed to be locked. The smoke alarms and carbon monoxide detectors were found in working condition. The dining room has enough seating for (3) residents, and the outdoor space has enough seating for (3) residents and observed furniture ready to be set up in the garage. LPA observed the home has activities for residents to engage in. The hot water temperature was recorded in the kitchen sink at 115.3F, and the phone was observed to be operational at (858-667-3015). No bodies of water or firearms are being kept in the facility.

An exit interview was conducted were this report was reviewed and provided to the applicant, Kiminyei Mildred
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023
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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