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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881446
Report Date: 08/02/2024
Date Signed: 08/02/2024 12:42:14 PM


Document Has Been Signed on 08/02/2024 12:42 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:MAHOGANY HILLS RESIDENCEFACILITY NUMBER:
331881446
ADMINISTRATOR:MANALANSAN, SUZETTEFACILITY TYPE:
735
ADDRESS:30387 REDDING AVETELEPHONE:
(951) 294-0356
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:4CENSUS: 0DATE:
08/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 AM
MET WITH:Staff, Donald AguinaldoTIME COMPLETED:
12:50 AM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Staff, Donald Aguinaldo, 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 (5) bedrooms and (3) 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, hygiene supplies, 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. The sharp and dangerous objects were observed to be locked and inaccessible. Hot water temperature was read at and carbon and smoke alarms were operational during the visit.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition.

Administration: The listed administrator possesses a current administrator's certificate. LPA observed where client and resident records will be stored.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
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: MAHOGANY HILLS RESIDENCE
FACILITY NUMBER: 331881446
VISIT DATE: 08/02/2024
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Health Related Services/ Incidental Medical Services: LPA observed the locked medication for 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.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
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