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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881463
Report Date: 05/28/2024
Date Signed: 05/28/2024 10:09:10 AM

Document Has Been Signed on 05/28/2024 10:09 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HILLS OF SOUTH CREEK II, THEFACILITY NUMBER:
331881463
ADMINISTRATOR/
DIRECTOR:		RAMIREZ, SOPHIAFACILITY TYPE:
740
ADDRESS:39890 SOUTH CREEK CIRCLETELEPHONE:
(714) 430-7672
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 6CENSUS: 0DATE:
05/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Applicants, Maricel Nepomuceno and Allen MedinaTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Janira Arreola, conducted an announced visit for the purpose of conducting the prelicensing inspection. LPA met with applicants Maricel Nepomuceno and Allen Medina for the visit. The applicant is seeking an initial application for an residential care facility for the elderly with a capacity for (6) residents, ages 60 and up.

LPA conducted a walk through of the interior and exterior of the facility. The home is a (5) bedroom, (3) bathroom, one story home with attached garage. The fire clearance conducted by Riverside County Fire Department was approved the home for (5) non-ambulatory residents and (1) bedridden resident in the master bedroom. The other resident bedrooms were observed to have the required furniture. (2) First aid kits were observed, and emergency supplies in the facility kitchen. The facility kitchen has enough pots and pans, cooking utensils, plates and cups for (6) Residents. The kitchen had the required food items. Kitchen knifes will be kept locked with cleaners under the sink. The laundry room was observed was in good repair and the facility possesses cleaning supplies to conduct regular cleaning of the facility. These items are located in the facility locked garage, and locked in the laundry room. The outdoor area was (1) exit and was found to be free of hazards. The land line was observed to be operational (951-506-3838). No bodies of water or firearms are being kept in the facility.

An exit interview was conducted were this report was reviewed and provided to the applicant Maricel Nepomuceno.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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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