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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881499
Report Date: 06/19/2024
Date Signed: 06/19/2024 01:07:55 PM

Document Has Been Signed on 06/19/2024 01:07 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:JUMANO DR HOME LLCFACILITY NUMBER:
331881499
ADMINISTRATOR/
DIRECTOR:
MARTIN, ROY L. IIFACILITY TYPE:
735
ADDRESS:25850 JUMANO DRIVETELEPHONE:
(951) 601-9925
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 4CENSUS: 3DATE:
06/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Roy Martin - LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an announced visit to the facility for the purpose of a Pre-Licensing inspection. LPA met with Licensee Roy Martin and was granted entry. Fire clearance was granted on 01/17/2024 for a total of four (4) clients. LPA observed the following:

Facility is a one-story building with four (4) client bedrooms, and two (2) bathrooms, a staff office, laundry room, living room, dining area, and kitchen. LPA observed clients bedrooms with the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, lighting, and emergency lighting. Client bathrooms had clean appliances that were operating in safe and sanitary condition and the showers contained non-slip mats. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Client and staff files will be located in cabinets in the staff office. Client medication with be centrally stored and locked in the dining room. The facility does not have any bodies of water on the property. There is a covered area with seating for the all the clients. All passageways were free from obstruction. LPA observed multiple charged fire extinguishers in the facility. The smoke detectors and carbon monoxide alarms were operational. The facility does not have any firearms and ammunition on the property. LPA observed required postings including the visitation polices, emergency/disaster plans, complaint procedures, and personal rights. Facility contains emergency supplies and first aid kits with the required items. The facility has working telephone for client use.



LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA determined the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete, and this facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Licensee Roy Martin.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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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