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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881494
Report Date: 07/05/2024
Date Signed: 07/05/2024 04:00:36 PM

Document Has Been Signed on 07/05/2024 04:00 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:RED MAHOGANY HOMEFACILITY NUMBER:
331881494
ADMINISTRATOR/
DIRECTOR:
LENZY, TOMIKAFACILITY TYPE:
735
ADDRESS:13659 RED MAHOGANY DR.TELEPHONE:
(909) 504-6010
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 3CENSUS: 0DATE:
07/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:33 PM
MET WITH:Applicant, Tamika LenzyTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Janira Arreola, made an announced visit to the facility in order to conduct a pre licensing inspection. LPA met with Applicant, Tamika Lenzy, who was informed of the purpose of the visit.

The facility is seeking an initial license for an adult residential facility, with capacity of (3) ambulatory clients approved by the local fire department. The facility does not have a pool or firearms. The home is a one story home with (3) bedrooms and (2) bathrooms.

LPA conducted a walk through of the interior and exterior of the facility. LPA observed required postings in facility hallways. The bedrooms have all the required furniture, hygiene supplies, and linens. LPA observed the carbon monoxide detectors were in good working condition. The outdoor area was free of any hazards and had a shaded area for residents and an emergency exit. The kitchen had the ability to prepared food is a clean and safe environment. LPA observed the food supply met the department requirements. LPA observed locked areas designated for medication, sharp objects, and cleaning supplies. The hot water temp was measures at 120F. The facility has a land line at (951) 208-1541 . Common spaces are available for clients to engage in activities. LPA observed areas were the staff and resident files will be kept. Emergency supplies are retained by the facility, including a complete first aid kit.

There are no objections for the applicant to proceed in the pre licensing process. An exit interview was conducted where a copy of this report was reviewed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2024
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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