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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881492
Report Date: 12/21/2023
Date Signed: 12/21/2023 09:53:54 AM

Document Has Been Signed on 12/21/2023 09:53 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:LUCENA ARF #2FACILITY NUMBER:
331881492
ADMINISTRATOR:LUCENA, VANESSAFACILITY TYPE:
735
ADDRESS:14497 PHILO ST.TELEPHONE:
(951) 330-1991
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 0DATE:
12/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Vanessa Lucena, ApplicantTIME COMPLETED:
10:00 AM
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On 12/21/2023, Licensing Program Analyst (LPA), Chinwe Nwogene conducted an announced pre-licensing inspection at the facility. LPA Nwogene met with Applicant, Vanessa Lucena and toured the facility.

Application: The application is for a Residential Care Facility for Adults. The fire clearance has been granted for four (4) non-ambulatory residents.

Buildings and Grounds: The home is composed with Family room, kitchen, and dining room combination, Livingroom, three (3) client bedrooms of which one is a shared bedroom, 2 restrooms, a storage 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 Vanessa, 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 a grab bar and non-slip mats available. The bathroom sink hot water was tested and measured at 137 degrees Fahrenheit which is above regulatory limits. Vanessa stated the hot water heater will be adjusted and a picture of the adjusted water temperature will be provided to LPA. 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 cabinet in the kitchen, 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 garage, inaccessible to clients. A Fire extinguisher was available and fully charged.

CONTINUE ON LIC809-C

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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: LUCENA ARF #2
FACILITY NUMBER: 331881492
VISIT DATE: 12/21/2023
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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. There was an umbrella that provides 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 drawer, 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. The fridge was measured at 0 degrees Fahrenheit and Freezer was measures at 37 degrees Fahrenheit.

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



Missing item.
Hot water temperature

LPA Nwogene will inform the Centralized Applications Bureau (CAB) that the home is ready for licensure when a picture of the adjusted hot water temperature has been received.

An exit interview was conducted were this report was discussed with and provided to Vanessa Lucena.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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