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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881448
Report Date: 07/27/2023
Date Signed: 07/27/2023 10:19:47 AM

Document Has Been Signed on 07/27/2023 10:19 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:MIRA MOSA PLACEFACILITY NUMBER:
331881448
ADMINISTRATOR:DUCLAYAN, DAMON M.FACILITY TYPE:
735
ADDRESS:37721 RUSHING WIND PLTELEPHONE:
(951) 526-4594
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 4CENSUS: 0DATE:
07/27/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Damon M. DuclayanTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At 9:30 AM, LPA met with Administrator Damon M. Duclayan. An initial application to operate an Adult Residential Facilities (ARF) was submitted to the Central Applications Bureau (CAB) on 04/25/2023 for a total capacity of four (4) residents. Fire clearance was granted on 05/12/2023. LPA Kathleen Banrasavong observed the following:
Structure:
Facility is a one-story house with four (4) resident bedrooms, one (1) resident bathrooms, living room, dining area and kitchen. There was an attached three car garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system are installed and operable.
Bedrooms:
Each resident bedroom #1, #2, #3, #4 were in good repair. Four (4) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm and carbon monoxide alarms.
Bathrooms:
One (1) resident bathroom has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and hand soap dispensers. At 09:56 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 106 degrees Fahrenheit.

(CONTINUED FROM LIC 809)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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: MIRA MOSA PLACE
FACILITY NUMBER: 331881448
VISIT DATE: 07/27/2023
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(CONTINUATION FROM LIC809C)
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp drawer will be secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition.
Pantry had sufficient storage for non-perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the house. Laundry detergents and cleaning supplies were observed in a closet away from residents.
Living/Family room:
There was a living room with furniture for all clients and TV.
Linens and Hygiene Supplies:
An adequate supply of linens and hygiene supplies was stored in a cabinet in the hallway of the residence.
Yards/Outside:
Patio table and chairs were observed in the backyard. There was a gate on the north side and a self-latching lock. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted at the exits in the house. Ombudsman poster, Let-Us-No poster, Rights of Resident Council, Theft & Loss, Personal rights, Non-discrimination observed.
General items:
One (1) fire extinguisher was charged and located in the living room; last inspection date of 04/17/2023. Nine (9) dual smoke alarms and carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the kitchen dining room area. First Aid kit with required components were observed. There was a locked area for medication storage. Emergency food and water supply was observed.
Component III was done on July 19, 2023, at 12:00PM at Riverside RO. Pre-Licensing is complete and this facility has no deficiencies. An exit interview was conducted, and a copy of this report was given Administrator, Damon M. Duclayan.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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