331881453-10-10-2023-18-AS-CGOH-CWGSXZ-20231010141646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881453
Report Date: 10/10/2023
Date Signed: 10/10/2023 02:16:50 PM

Document Has Been Signed on 10/10/2023 02:16 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:	PRESENT MOMENTS SENIOR LIVING LLC		FACILITY NUMBER:	331881453
ADMINISTRATOR:	GLADDEN, AMY		FACILITY TYPE:	740
ADDRESS:	1582 SUNRISE DR		TELEPHONE:	(951) 662-5688
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	6	CENSUS: 0	DATE:	10/10/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:14 PM
MET WITH:	Administrator		TIME COMPLETED:	02:16 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) Cheryl Goodrich arrived at 1:14 pm. to conduct an announced pre-licensing visit. LPA met the Administrator, Amy Gladden at the front door and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6 and has met pre-licensing requirements to open facility. Facility is approved for six (6) non-ambulatory residents with 0 residents in care. 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 71 degrees. The facility consists of 4 resident bedrooms, and 4 bathrooms, living room, kitchen, and backyard. The bedrooms are furnished with tv, lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the locked office and inaccessible to the resident. The facility and has a current fire clearance, smoke and carbon detectors and fire extinguishers and are in working order. Personnel Records-Training: The staff records are not available at this time due to no staff being employed. Client Records-Incident Reports: The facility has a binder that will contain identification and emergency information, physician’s report, resident appraisal, IPP, client rights, and admissions agreement. The facility currently does not have any residents in care. (Continued on LIC809-C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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: PRESENT MOMENTS SENIOR LIVING LLC	FACILITY NUMBER: 331881453
	VISIT DATE: 10/10/2023

NARRATIVE

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(Continued from LIC809)

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 logs will be in the resident's files, 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 last fire drill was completed 10/09/23. The facility has emergency supply of food and water.
Summary: Based on today's visit, no deficiencies were observed at this time. The facility has completed their pre-licensing requirements. An exit interview was conducted with Administrator, Amy Gladden and a copy of this report was printed Signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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