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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881502
Report Date: 08/01/2024
Date Signed: 08/01/2024 09:47:56 AM

Document Has Been Signed on 08/01/2024 09:47 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:WHITE BOX LANE HOME LLCFACILITY NUMBER:
331881502
ADMINISTRATOR/
DIRECTOR:		MARTIN, ROY L. IIFACILITY TYPE:
735
ADDRESS:14940 WHITE BOX LANETELEPHONE:
(951) 924-3459
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 5DATE:
08/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:May Embalsado, AdministratorTIME VISIT/
INSPECTION COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an announced pre-licensing inspection at the home and met with Administrator, May Embalsado.

Application: The application is for an Adult Residential Facility (ARF), change of ownership. The fire clearance has been granted for six (6) non-ambulatory clients. Buildings and Grounds: The home is composed of four (4) client bedrooms, one (1) staff bedroom, one (1) living room, three (3) bathrooms, a laundry room, open kitchen and dining room, a garage, and front and back yard areas. The interior and exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors are in working order. There are no pools or other bodies of water located at the home. According to the Administrator, there are no weapons stored in the home. Rooms, furniture, and beds appeared to be in good repair. The bedrooms are fully furnished, and privacy is available. The dining and living room areas are clutter free and in good condition. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer were available and in working order. The home is in good condition and exceptionally clean and organized. Storage and Supplies: Medications will be stored in a locked medication cart, inaccessible to any unauthorized individuals. Secured areas are available for facility files, staff files and client files. A complete first aid kit was observed to be available. Cleaning supplies will be stored away in a secured location. Linens, and equipment appeared to be in good repair and sufficient for the approved census. Fire extinguishers were available and fully charged.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 cabinet, available only to authorized individuals. Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan, Personal Rights, and Facility Sketch.

No corrections were observed to be needed at time of inspection. The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensing. This report was discussed with, and a copy provided to Administrator Embalsado.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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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