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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881426
Report Date: 07/13/2023
Date Signed: 07/13/2023 09:56:08 AM

Document Has Been Signed on 07/13/2023 09:56 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DUNLAVY HOUSEFACILITY NUMBER:
331881426
ADMINISTRATOR:DLAMINI, KHUMBUZILEFACILITY TYPE:
735
ADDRESS:24615 DUNLAVY CTTELEPHONE:
(559) 410-6555
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 0DATE:
07/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Peter Nganga TIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Sara Martinez conducted an announced visit to complete the Pre-licensing inspection. LPAs met with Licensee, Peter Nganga for an Adult Residential Facility with a capacity of four (4) residents.

The facility is a five (5) bedroom, two (2) bath home. There are four (4) client bedrooms, one (1) staff bedroom, one (1) staff office, kitchen/dining area, one (1) living room areas, a laundry room, backyard, and attached garage. LPA toured the interior and exterior areas of the facility. The following were inspected:



Client Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, lighting, and emergency lighting.

Client Bathrooms: The bathroom appliances were operating in safe and sanitary condition. The bathrooms have non-slip mats.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter top were free of debris and in good repair. The knives and sharp objects were locked in the drawers. The water temperature was measured by LPA, the thermometer read at 109 degrees F.

Staff Office: The office consists of two (2) storage lockers for client/staff files and a locked medication cart.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DUNLAVY HOUSE
FACILITY NUMBER: 331881426
VISIT DATE: 07/13/2023
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Common Sitting Areas: There is adequate seating in the common areas. The facility has a supply of activities for the clients.

Laundry Room/ Garage: The laundry room is near the entry to the garage. The garage will be locked at all times and will need a password/fingerprint entry to enter. The chemicals and laundry soap will be locked away in a hallway closet that also requires a password/fingerprint entry to enter.



Linens and Hygiene Supplies: An adequate supply of linens were available.

Backyard: There are no bodies of water in the backyard. There is a covered area with seating for the all the clients. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There are four (4) charged fire extinguishers in the facility. LPA observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and ammunition.

Postings: LPAs observed required postings including the visitation polices, emergency/disaster plans, complaint procedures, and personal rights.

First aid and working telephone: The facility was equipped with a complete first aid kit and manual. The facility has working telephone for client use.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA have determined that the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete, and this facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Licensee Peter Nganga.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC809 (FAS) - (06/04)
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