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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881519
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:58:11 PM

Document Has Been Signed on 08/20/2024 02:58 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:K & L MADISON COURTFACILITY NUMBER:
331881519
ADMINISTRATOR/
DIRECTOR:		MICHAUD, LEVIFACILITY TYPE:
735
ADDRESS:27118 MADISON COURTTELEPHONE:
(760) 580-6475
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 4CENSUS: 0DATE:
08/20/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Kody Jackson & Levi Michaud, applicantsTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analysts (LPAs) Seo Jeon, Andrei Castillo and Ferrer Sabarias made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPAs met with Applicants, Kody Jackson and Levi Michaud, who accompanied LPAs for the inspection. The Applicants have submitted an application for four(4) residents. On 4-11-2024 the Riverside County Fire Department approved a fire clearance for which the applicant has applied for.

Facility is a one-story building with 4 client bedrooms, 2 bathrooms, laundry room, living room, dining area, kitchen and attached garage. LPAs observed clients’ bedrooms with the required bedding and furniture, such as, clean mattresses/linen, night stands, 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 surface. 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 in locked cabinet in the hallway. Client medication will be centrally stored and locked in the kitchen cabinet. The facility has no pool or any body of water. There is a covered area with seating for the all the clients. All passageways were free from obstruction. LPA observed 2 charged fire extinguishers in the facility. The smoke detectors and carbon monoxide alarms were operational. The facility does not have any known 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.



Continued on LIC809-C...
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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 2
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: K & L MADISON COURT
FACILITY NUMBER: 331881519
VISIT DATE: 08/20/2024
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LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. The applicants successfully completed COMP III orientation on 8-20-2024.

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 applicants, Kody Jackson and Levi Michaud.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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