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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881479
Report Date: 12/01/2023
Date Signed: 12/01/2023 12:44:26 PM

Document Has Been Signed on 12/01/2023 12:44 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A & S SENIOR QUALITY CAREFACILITY NUMBER:
331881479
ADMINISTRATOR:FUENTES, TERESAFACILITY TYPE:
740
ADDRESS:17764 ROBUSTA DRIVETELEPHONE:
(909) 548-1769
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 6CENSUS: 6DATE:
12/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:LICENSEE, NITIN VERMANITIME COMPLETED:
12:58 PM
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On December 1, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived for a scheduled visit for the purpose of conducting a pre-licensing Change of Ownership (CHOW). LPA Mixson met with Licensee, Nitin Vermani, introduced herself, and stated the purpose of the visit.

The location is a single-story home located at 17764 Robusta Drive, Riverside, CA. 92503 and has five bedrooms, three bathrooms, a living room, dining room, and a kitchen, with a three car garage, and backyard and front yard. The Riverside County Fire Department approved this facility for five (5) Non-Ambulatory residents, one (1) Bedridden resident for a total of (6) six, on 07/24/2023. The home has a first aid kit and manual, the Administrator has received First Aid and CPR training, and their Administrator’s certificate is current. LPA Mixson observed where medications are stored, locked, and inaccessible to the residents. The home is equipped with lights in the passages and stocked with emergency night lights throughout the home. The smoke and carbon monoxide detectors were observed and are operable. LPA Mixson observed the fire extinguishers, it was charged and in the green, and last charged on 2023. The cleaning supplies were locked and inaccessible, along with the sharp objects. The knives were locked in a kitchen drawer, plenty of pots, pans, and other kitchen accessories. The facility has the required seven day supply of non-perishable food items and the two day supply of perishable food items. LPA Mixson observed hygiene supplies for residents. All doors, and passageways are clear of obstruction. There were no bodies of water on the premises, and the fireplace was covered with screen. There was enough clean linen and hygiene items, and there was appropriate lighting in each room. LPA Mixson observed central heating and air conditioning systems, and they are operable. The Administrator dialed the land line phone number (951) 353-1612, and it was operable. Outside/Yards: Had shade and covering for shaded visit, and activities, and there were no obstructions observed. The Licensee stated there were no firearms, and/or ammunition on the premises.
CAB 8.0 Pre-licensing / COMP III Requested 11/27/2023, days available whenever available in December. An exit interview was conducted, a copy of this report was provided to the Licensee, Nitin Vermani.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2023
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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