<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881495
Report Date: 06/18/2024
Date Signed: 06/18/2024 11:29:32 AM

Document Has Been Signed on 06/18/2024 11:29 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:SHADOWBROOK ST HOME LLCFACILITY NUMBER:
331881495
ADMINISTRATOR/
DIRECTOR:
MARTIN, ROY L. IIFACILITY TYPE:
735
ADDRESS:12640 SHADOWBROOK STREETTELEPHONE:
(951) 377-3763
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 4DATE:
06/18/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Roy Martin, Administrator TIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Javina George made an announced visit to the facility for the purpose of conducting a prelicensing inspection due to a change of ownership. LPA met with Applicant Roy Martin, Administrator whom accompanied LPA for duration of the visit. On 1/12/24 the Riverside County Fire approved a fire clearance for four (4) non ambulatory occupants.

During today's visit LPA conducted a tour of the interior and exterior of the home. The home is a single story house consisting of (5) bedrooms, of which 1 bedroom is for a live-in caregiver and (2) bathrooms, backyard, garage, dining room, family room and living room. The bedrooms were observed to have the required furniture (bed, chest of drawers, and adequate lighting). The bathrooms has grab bars, and non skid mats. The hot water was checked and measured 104.4-112.6 degrees Fahrenheit. The smoke and carbon monoxide detectors were checked and found to be operable. There are no pools or bodies of water, or no known guns or ammunition on the premises.

The facility has extra linen, dishes and utensils that are in good repair. The facility has plenty of activities available for the clients to use that encourage socialization such as board games, and a garden (orange trees, sugar cane). The facility has emergency food and water, and was observed to have flashlights, and night lights. The facility was observed to have a 2 day supply of perishable and a 7 day supply of non perishable food items. The medications are stored in a locked cabinet inside the kitchen. The chemicals and sharp objects are stored in a locked cabinet underneath the kitchen sink. The facility has a fully charged fire extinguisher. The facility was observed to have the required postings (personal rights, CCL complaint poster, theft and loss policy). The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22. Based on the observations and evaluation of the facility this date, the facility’s ready for licensure.

Applicant/Administrator will be notified once facility is licensed. An exit interview was conducted, and a copy of this report (LIC809) was discussed and provided with Applicant/Administrator Roy Martin.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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 1