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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881475
Report Date: 07/25/2024
Date Signed: 07/25/2024 12:35:27 PM

Document Has Been Signed on 07/25/2024 12:35 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:CARMELITE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
331881475
ADMINISTRATOR/
DIRECTOR:		ROSANA, BIENVENIDOFACILITY TYPE:
735
ADDRESS:245 E SIXTH STREETTELEPHONE:
(562) 453-9838
CITY:SAN JACITOSTATE: CAZIP CODE:
92583
CAPACITY: 58CENSUS: 0DATE:
07/25/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Applicant Bienvenido RosanaTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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On 7/25/24 Licensing Program Analyst (LPA) Valerie Flores, Seo Jeon and Licensing Program Manager (LPM) Rikesha Stamps made an announced visit to the facility for the purpose of conducting a prelicensing inspection. LPA met with Applicant/Administrator Bienvenido Rosana, who accompanied LPAs for the inspection. The Applicant has submitted an application for 58 residents to which 48 are ambulatory and 10 are nonambulatory. On 4/29/24 the Riverside County Fire Department approved a fire clearance for which the applicant has applied for non-ambulatory residents in room 1,2,8,9, and 10 and ambulatory in all the other rooms. The facility has no hospice residents in care and do not have any approved/pending hospice waivers.

The facility is a single-story triplex unit consisting of 32 bedrooms.Building A is identified as the main building which has 10 resident rooms to which all are equipped with a bathroom inside the bedrooms, two (2) staff rooms and two (2) staff designated bathrooms.

Building B has 13 bedrooms of which room 20, 24, 28, and 32 have a private bathroom. In addition, building B has four (4) shared bathrooms located in the commons areas designated for resident use.

Building C has 5 resident rooms to which all are equipped with bathrooms inside the residents room and an attached laundry room which includes two (2) washer machines and two (2) dryers.

Interior/exterior passageways are free from obstructions. The bedrooms were observed to have the required furniture; bed, lighting, night stands, chairs, and chest of drawers for storing clothing. The bathrooms had non-skid materials, and grab bars. There is plenty of extra linen (sheets, blankets, towels) stored in building A. The carbon monoxide detectors and smoke alarms were tested and found to be operable.The hot water temperature was measured throughout the facility and measured 110.3 -111.3 degrees Fahrenheit. Camera's are located in the interior of Building A and B and are inoperable.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: CARMELITE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 331881475
VISIT DATE: 07/25/2024
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Applicant foresees to get approval in the future for video surveillance use. The facility has an approved emergency disaster plan, infection control training plan on file posted in the dining room. The facility has a sufficient supply of dishes, cooking and eating utensils, that were observed to be in good repair.

The facility food supply was observed to be sufficient as there was 2-day supply of perishable and a 7-day supply of nonperishable food items. The facility has an emergency food and water supply. The facility is equipped with a pull cord signalling system in each residents bedrooms. There is a fully stocked first aid kit. The facility had a designated locked cabinet for sharps and chemicals/pesticides. Medications were observed to be locked, inaccessible to residents, and centrally stored in the kitchen and living room area. Fire extinguishers were fully charged and dated for 1/22/24. The facility was observed to have activities to encourage socialization such as books and board games. Posted in the dining room was an activities schedule and food menu for all residents to see.

Per Bienvenido, facility does not have any firearms or ammunition stored on grounds. Facility sketch, LTCO information and Employee rights are all posted in the dining area.

Based on today's inspection it is the recommendation that the home be licensed once the following is completed:

- Building C residents window screens need to be in good repair.
- Building B the emergency exit door is in disrepair, there is a significant crack down the middle of the door.
- LPA observed cockroaches throughout the facility. The facility shall be free insects, this matter shall be
resolved.
- Update the floor plan sketch to identity to identify staff rooms for live-in, also indicate which rooms will be
used by residents. Update the plan of operations to indicate live-in staff at the facility.

An exit interview was conducted with applicant Bienvenido and a copy of this report was provided to applicant.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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