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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881436
Report Date: 08/08/2024
Date Signed: 08/08/2024 03:59:40 PM


Document Has Been Signed on 08/08/2024 03:59 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:DOLORES HOMECARE IIFACILITY NUMBER:
331881436
ADMINISTRATOR:CAYABYAN, ANSONFACILITY TYPE:
740
ADDRESS:68280 MARINA ROADTELEPHONE:
(760) 218-8906
CITY:CATHERDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:6CENSUS: 6DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Analisa Cayabyab, administratorTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA), Seo Jeon, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was allowed to enter the facility to conduct the inspection. On today’s visit the LPA met with Analisa Cayabyab, administrator, and she was notified of the purpose for the visit.

Infection Control: LPA observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures.

PHYSICAL PLANT: The Licensee is operating the facility within the conditions and limitations specified on the license. Clients appear to be protected against immediate hazards. Outdoor and indoor passageways are kept free of obstruction. There is a fenced swimming pool with locked gate that is in compliance on the property. According to staff, there are no weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to clients in care. A comfortable temperature was being maintained in the home. There was sufficient lighting in all rooms to ensure the comfort and safety of clients. Hot water was tested and observed to be within regulatory requirements. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. Additional equipment for physically handicapped clients is available. The smoke and carbon monoxide alarms were tested and found to be operable. Fire extinguisher located in the family room has current tag. The interior and exterior areas of the home were observed to be very clean and safe.

Continued on LIC809C...

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo JeonTELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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: DOLORES HOMECARE II
FACILITY NUMBER: 331881436
VISIT DATE: 08/08/2024
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FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. The kitchen was observed to be clean.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients. Floor plans, telephone numbers and personal rights were found in the facility. LPA observed valid administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed five (5) staff files and reviewed the facility's staff schedule. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Four (4) resident files were reviewed, and the possessed all required paperwork.



Health Related Services/ Incidental Medical Services: All client medication was locked in a medication cabinet. LPA reviewed client medications for (3) clients and found all medication records. All required labeling was found to be in place, and all medication was accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards. LPA observed emergency supplies in the facility pantry.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted where a copy of this report was provided to administrator, Analisa Cayabyab.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo JeonTELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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