331881510-7-24-2024-18-AS-SJEN-D7H2W3-20240724174453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881510
Report Date: 07/24/2024
Date Signed: 07/24/2024 05:45:06 PM

Document Has Been Signed on 07/24/2024 05:45 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:	AMPM COMFORT CARE, INC.		FACILITY NUMBER:	331881510
ADMINISTRATOR:	AGUINALDO, RUSSELL		FACILITY TYPE:	740
ADDRESS:	30096 ALEXANDER DRIVE		TELEPHONE:	8189660088
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY:	6	CENSUS: 0	DATE:	07/24/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Russell Aguinaldo, administrator		TIME COMPLETED:	05:50 PM

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	On 7/24/24 Licensing Program Analyst (LPA) Seo Jeon and Licensing Program Manager (LPM) Rikesha Stamps made an announced visit to the facility for the purpose of conducting a prelicensing inspection. LPA met with Applicant/Administrator Russell Aguinaldo, whom accompanied LPA for the inspection. The Applicant has submitted an application(change of ownership) for 6 residents (6 non ambulatory of which 1 maybe bedridden). On 11/7/23 the Riverside County Fire Department approved a fire clearance for which the applicant has applied for (bedroom #1), is specifically for a bedridden resident and rooms 2, 3, 4 and 5 are for non-ambulatory residents. The facility has an approved hospice waiver for 6. The home is a single story structure consisting of (5) bedrooms, (4) bathrooms, kitchen, formal dining room, family room, garage, backyard with sufficient shaded areas, locked and fenced pool. The bedrooms were observed to have bed, lighting, night stand, chest of drawers and area for sitting. The bathrooms had non-skid mats, and grab bars. There is plenty of extra linen (sheets, blankets, towels) that were observed to be in good repair. The smoke and carbon monoxide detectors are a dual system that were tested and found to be operable. The hot water temperature was tested and was found to be higher than regulatory limits measuring at 125.6 degrees Fahrenheit. The facility has an emergency disaster plan, dementia plan and infection control training plan on file. The facility has a sufficient supply of dishes, cooking and eating utensils, that were observed to be in good repair. The facility food supply was observed to be sufficient as there was 2 day supply of perishable and a 7 day supply of nonperishable food items. The facility has an emergency food and water supply. There is a fully stocked first aid kit. The facility was observed to have activities to encourage socialization such as, (i.e., cards, books and board game as well as a gazebo with plenty of shades in addition to outdoor space for walking)

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AMPM COMFORT CARE, INC.	FACILITY NUMBER: 331881510
	VISIT DATE: 07/24/2024

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The passageways and inclines are clear and free from obstruction. The home has 1 fully charged fire extinguisher. The facility does not have any known guns or ammunition stored on grounds. The sharps/knives are stored in a locked cabinet next to the refrigerator. The medications will be centrally stored in locked cabinet in dining area.

Upon entry to the home in the foyer on the right wall the required postings (facility sketch, resident council, theft and loss policy, personal rights, PUB475 CCL/dept complaint poster and the Long term Care Ombudsman poster were observed to be posted.

The applicant is scheduled to complete COMP III orientation on 7-25-2024.

Based on today's inspection it is the recommendation that the home be licensed once the following is completed:

- hot water temperature to be between 105 and 120 degrees Fahrenheit.
- pending completion of Comp III.

An exit interview was conducted and a copy of this report was provided to applicant

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC809 (FAS) - (06/04)

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