331881441-10-27-2023-18-AS-JSRS-CWZRQM-20231027131347

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881441
Report Date: 10/27/2023
Date Signed: 10/27/2023 01:13:55 PM

Document Has Been Signed on 10/27/2023 01:13 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	WARREN MENIFEE GUEST HOME		FACILITY NUMBER:	331881441
ADMINISTRATOR:	WARREN, GLADYS M.		FACILITY TYPE:	735
ADDRESS:	27962 MERBIE CIRCLE		TELEPHONE:	(909) 975-8115
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92585
CAPACITY: 4		CENSUS: 0	DATE:	10/27/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Gladys Warren, Licensee		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an announced Pre-licensing visit at Warren Menifee Guest Home for licensure. The LPA was greeted and granted entrance into the home by Licensee, Gladys Warren. Application: The application is for an Adult Residential Facility. The fire clearance has been granted for residential care for four (4) ambulatory adults ages 18 through 59 and stipulates the second floor and garage shall not be used for care. Buildings and Grounds: The home is a six (6) bedroom, four (4) bathroom two story home and is composed of a living room, a family room, kitchen, dining area, laundry room, garage and a backyard area. There are three (3) bedrooms upstairs and two (2) bathrooms upstairs that are designated as the Licensee's living quarters. The downstairs area of the home is designated for client use and contains three client bedrooms, one full bath with tub and shower, and one half bath. During a tour of the client bedrooms and bathrooms downstairs, the following observations were made: - LPA observed bedroom one (1) to be a private bedroom that shares a full bathroom with bedroom two (2). Bedroom two (2) is set up to for two clients to share. LPA observed bedroom three (3) to be set up as a private bedroom for one client. LPA observed that in order for client from bedroom three (3) to take a bath or shower, he/she would have to walk through bedroom one (1) or bedroom two (2) to get to the bathroom to shower and bathe. LPA advised Licensee that no client bedroom shall be used as a public or general passageway to another room, bath or toilet. (Per CCR 85087(a)(4). Continue on LIC 890C

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

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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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: WARREN MENIFEE GUEST HOME	FACILITY NUMBER: 331881441
	VISIT DATE: 10/27/2023

NARRATIVE

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Licensee discussed options with LPA to remain be in compliance. Licensee informed LPA that she will make the following changes: Bedroom one (1) will be changed from a single occupancy to a double occupancy bedroom, and bedroom three (3) will be changed from a private bedroom to a staff office. LPA advised Licensee to submit a revised Facility Sketch Floor plan along with a revised Plan of Operation to the Department. Licensee will also contact the Department once the changes have been made.

LPA continued the tour of the facility. The exterior pathways of the home were observed to be clutter free with no obstructions present. There are no pools or other bodies of water located at the home. Interior passageways were clear and free of obstruction. The bedrooms are completely furnished with a bed, night stand, dresser, chair, adequate lighting and privacy is available. Night lights were observed in the hallways. The facility currently has linens, towels and a sufficient amount of hygiene products for clients. According to Licensee, there are no weapons stored in the home. Rooms, furniture ,beds, mattresses are all in good repair. The dining and living room areas are clutter free and appropriately furnished. The hot water temperature was tested and measured at 113 degrees Fahrenheit, which was within regulatory limits. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer are available and in working order. Smoke and Carbon Monoxide detectors were tested and operable. The phone number designated for the facility is (909) 899-2880. The fire inspection was conducted and approved on 5/1/2023. The emergency exits are free of obstruction. The facility has an alarm system and one camera in the formal living room.

Storage and Supplies: Medications will be stored inaccessible to any unauthorized individuals. Secured areas are available for facility files and client files. The First Aid kit was observed to be available and complete. Cleaning supplies will be stored away in a locked cabinet in the laundry room. Linens, personal hygiene supplies, and equipment are all in good repair and sufficient for approved census. Bathrooms were observed to have grab bars, non-slip bath mats, closed-lid waste baskets, and hand-washing signage posted by the sinks. Two (2) fire extinguishers are available and fully charged.

Food Service: The kitchen was observed to have dishes, silverware, pots, and pans. Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps are stored in a secured kitchen drawer, available only to authorized individuals. The refrigerator temperature measured 40 degrees.

Forms: The following forms were observed to be posted at the home: Emergency Disaster Plan (LIC 610D), Personal Rights, and Facility Sketch (LIC 999), Labor Law Information as well as other signage throughout the facility.

The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensure after said changes are made. This report was discussed with and a copy provided to Licensee, Gladys Warren.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC809 (FAS) - (06/04)

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