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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881501
Report Date: 06/19/2024
Date Signed: 06/19/2024 02:44:17 PM

Document Has Been Signed on 06/19/2024 02:44 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PALO CEDRO ST HOME LLCFACILITY NUMBER:
331881501
ADMINISTRATOR/
DIRECTOR:		MARTIN, ROY L. IIFACILITY TYPE:
735
ADDRESS:25719 PALO CEDRO DRIVETELEPHONE:
(951) 485-2451
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 4CENSUS: 1DATE:
06/19/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Applicant, Roy MartinTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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On 6/19/2024, Licensing Program Analyst (LPA), Janette Romero made an announced visit to conduct a pre-licensing evaluation and met with Applicant, Roy Martin and Administrator, May Embalsado. A change of ownership application to operate a Adult Residential Facility (ARF) was received by the Centralized Applications Bureau (CAB) on 2/13/2024. Fire Clearance was granted on 1/12/2024 for a total capacity of four (4) non-ambulatory clients. During today's visit, there was one (1) staff present and LPA was informed the client currently residing in the facility was out in the community.

LPA toured the facility with Applicant Martin and Administrator Embalsado. During the tour, LPA observed the facility is made up of a one (1) story home with three (3) client bedrooms, two (2) bathrooms, a staff room, kitchen, dining room, living room, and attached garage. The facility has a central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Administrator Embalsado tested one (1) of the smoke alarm/carbon monoxide detectors and LPA observed it to be operational. The facility has fire extinguishers mounted throughout the home, serviced on 4/26/2024. Client bedrooms are each furnished with a bed, chair, and night stand. Both bathrooms have a working toilet, wash basin and have paper towels, toilet paper, and soap readily available. The facility has additional clean towels and linens stored in a hallway cabinet. LPA toured the kitchen and observed the knives and sharp instruments stored in a kitchen cabinet secured with a master lock. Cleaning solutions and disinfectants are secured in a locked cabinet in the garage. The facility has an emergency water supply along with incontinent supplies stored in the garage. LPA observed the stove to be operational. Refrigerator/freezer are in working condition. The facility has more than a 2-day supply of perishable foods and 7-day supply of non-perishable foods. There is adequate seating for meals for the approved capacity. Medications are secured in a storage cabinet in the dining room. There is a swinging self-latching gate on the right side of the property. Indoor and outdoor pathways are free of obstructions. There was no bodies of water observed on the premises.

During today's visit, LPA did not observe any issues or concerns. Applicant Martin reported they attended COMP III on 6/14/2024 at the Riverside Regional Office. Final approval of licensure will be granted by CAB.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
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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