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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881449
Report Date: 10/31/2023
Date Signed: 10/31/2023 10:01:21 AM

Document Has Been Signed on 10/31/2023 10:01 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:VIDA HOME SERVICES AT SUGAR MAPLE INCFACILITY NUMBER:
331881449
ADMINISTRATOR:BALQUIEDRA, CHERYLFACILITY TYPE:
735
ADDRESS:3567 SUGAR MAPLE COURTTELEPHONE:
(818) 625-7103
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 4CENSUS: 0DATE:
10/31/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Administrator, Cheryl BalquiedraTIME COMPLETED:
10:01 AM
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Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 8:54 AM. to conduct an announced Pre-Licensing visit. LPA met the Administrator, Cheryl Balquiedra at the front door and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility meets the licensing requirements according to California Code of Regulations, Title 22, Division 6. The facility is approved for 4 residents ages 18 to 59
Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies.
Physical Plant and Environmental Safety: The facility temperature read at 70 degrees. The facility consists of 4 resident bedrooms and 2 resident bedrooms with a single bed in each room, 1 care staff bedroom with a bathroom, living room, kitchen, and backyard. The bedrooms are furnished with lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 114 degrees within regulation requirements. The living room and kitchen are clean and clear of obstruction. The medications are stored in a locked container in the kitchen and inaccessible to the resident. The facility and has a current fire clearance, smoke and carbon monoxide detectors and fire extinguishers and are in working order.
(Continued to LIC809-C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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: VIDA HOME SERVICES AT SUGAR MAPLE INC
FACILITY NUMBER: 331881449
VISIT DATE: 10/31/2023
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(Continued from LIC809)
Personnel Records-Training: There are no staff currently hired at this time. The Administrator’s records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings.
Client Records-Incident Reports: The facility has no residents in care and does not have any client reports including but not limited to identification and emergency information, physician’s orders, MAR, and additional assessments. The facility will handle the resident’s cash resources.
Client Rights-Information: The facility has client rights information posted in the facility.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available.
Health- Related Services: The facility has a medication logbook (MAR), however no records are present due to no residents in care.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The fire drills are completed each month. The facility has emergency supply of food and water.
Summary: Based on today's visit, no deficiencies were observed at this time. The Pre-Licensing inspection has been completed. An exit interview was conducted with Administrator Cheryl Balquiedra and a copy of this report was printed Signature below confirms receipt of these rights.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC809 (FAS) - (06/04)
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