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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881426
Report Date: 07/24/2024
Date Signed: 07/24/2024 04:13:53 PM

Document Has Been Signed on 07/24/2024 04:13 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DUNLAVY HOUSEFACILITY NUMBER:
331881426
ADMINISTRATOR/
DIRECTOR:		DLAMINI, KHUMBUZILEFACILITY TYPE:
735
ADDRESS:24615 DUNLAVY CTTELEPHONE:
(559) 410-6555
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 0DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:48 PM
MET WITH:Licensee, Peter NgangaTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Licensee, Peter Nganga who was informed of the purpose of the visit. At the time of the visit there was (1) staff present. The facility does not have clients in care.

The facility is a one story home with (4) bedrooms and (2) bathrooms with attached garage. No pools or firearms are being kept at the facility.

Infection Control: The LPA observed the hand washing stations in the facility, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has an infection control plan.



Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. The sharp and dangerous objects were observed to be locked and inaccessible.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DUNLAVY HOUSE
FACILITY NUMBER: 331881426
VISIT DATE: 07/24/2024
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Administration: The listed administrator, possesses a current administrator's certificate. LPA observed where client and resident records will be stored.

Health Related Services/ Incidental Medical Services: LPA observed the locked medication cabinet and refrigerator box for locking resident medications.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit with all required items.

No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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