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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881477
Report Date: 01/31/2024
Date Signed: 01/31/2024 03:53:56 PM


Document Has Been Signed on 01/31/2024 03:53 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:LIVING WATER ELDERCAREFACILITY NUMBER:
331881477
ADMINISTRATOR:MIKENAS, ANNIE JANEFACILITY TYPE:
740
ADDRESS:30210 POWDERHORN LANETELEPHONE:
(951) 837-0525
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 0DATE:
01/31/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:ANNIE JANE MIKENASTIME COMPLETED:
04:00 PM
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On 1/31/2024, Licensing Program Analyst (LPA), Chinwe Nwogene conducted an announced pre-licensing inspection at the facility. LPA Nwogene met with Applicant, Annie Jane Mikenas and toured the facility.

Application: The application is for a Residential Care Facility for the Elderly. The fire clearance has been granted for six (6) non-ambulatory residents.

Buildings and Grounds: The home is composed with living room, kitchen and dining room combination, four (4) clients bedrooms, 2 restrooms, a staff room, laundry room, backyard, and a garage. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Annie, there are no weapons stored in the home. Rooms, furniture, beds, mattresses are all in good repair. The bedrooms are furnished and privacy is available. The dining and living room areas/furniture are clutter free and in good condition. Bathrooms were observed to have non-slip mats and grab bar available. The hot water was tested and measured at 117 degrees Fahrenheit which is within regulatory limits. Outdoor areas had sufficient room for activities. A washing machine and dryer are available and in working order. Central heating and air conditioning system installed with a central panel located in hallway to control entire house.

Storage and Supplies: Medications will be stored in a locked hallway closet, inaccessible to any unauthorized individuals. Secured areas are available for facility files and resident files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away in the laundry room, inaccessible to clients. Fire extinguisher was available and fully charged.

CONTINUE ON LIC809-C

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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 3


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: LIVING WATER ELDERCARE
FACILITY NUMBER: 331881477
VISIT DATE: 01/31/2024
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CONTINUED FROM LIC809

Activities: Inside and outside, there are areas for residents to use for their leisure. Backyard is in good condition with a covered patio to provide shade over the outside table and chairs. Activity supplies are present inside the home, including television, magazines, and games.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps will be stored in a locked kitchen cabinet, available only to authorized individuals. Trash cans has tight-fitting lid. Dishwasher will be used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. Fridge and freezer are large enough to accommodate required perishable foods.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E), Theft and Loss Policies, Visitors Policy, Personal Rights, rights of resident council, a Facility Sketch (LIC 999), Labor Law Information, and Complaint Information.



LPA observed resident bedroom #1 was being used as a staff room and staff room being used as resident bedroom. Annie stated there was a mistake with the bedroom labeling on the facility sketch and a new facility sketch will be submitted.

Missing Item;
  • Updated Facility Sketch
  • Drawers for Resident bedroom #4


LPA Nwogene will inform the Centralized Applications Bureau (CAB) that the home is ready for licensure when proof of the missing items has been received.

An exit interview was conducted were this report was discussed with and provided to Annie Jane Mikekna.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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