331881532-6-19-2024-18-AS-YDEO-D6DQAC-20240619115943

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881532
Report Date: 06/19/2024
Date Signed: 06/19/2024 11:59:59 AM

Document Has Been Signed on 06/19/2024 11:59 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	A MODERN HOME FOR CARE, LLC		FACILITY NUMBER:	331881532
ADMINISTRATOR:	GALES, RENATO		FACILITY TYPE:	740
ADDRESS:	3151 STARGAZER STREET		TELEPHONE:	(213) 587-0412
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	6	CENSUS: 0	DATE:	06/19/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Renato & Tatiana Gales, Licensees		TIME COMPLETED:	12:00 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	Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:00 AM, LPA met with Licensees Renato & Tatiana Gales. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 11/21/2023 for a total capacity of six (6) ambulatory and zero (0) bedridden residents. Fire clearance was granted on 2/26/2024. LPA Delgado observed the following: Structure: Facility was a one-story house with four (4) resident bedrooms, two (2) resident bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Each resident bedroom #1-shared, #2-shared, #3 and #4 will accommodate any ambulatory residents. Four (4) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. (Continued on Page 2)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: A MODERN HOME FOR CARE, LLC	FACILITY NUMBER: 331881532
	VISIT DATE: 06/19/2024

NARRATIVE

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(Continued from Page 1)

Bathrooms:
Two (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:01 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 106.2 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked closet located near the front door. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the residence. Laundry detergents and cleaning supplies were observed in garage inaccessible to residents.
Living/Family room:
There was a living room with sufficient seating for all clients and a TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a closet in the main hallway of the residence. Hygiene supplies observed inside garage.
Yards/Outside:
Patio tables and sufficient chairs were observed in the backyard with shade. There was a gate on the South side of the property with a self-latch. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted near the designated exits. Obudsman poster and Let-Us-No poster observed.
General items:
Two (2) fire extinguishers were charged and located in the kitchen and laundry . Six (6) dual smoke/carbon monoxide alarms were tested and were observed to be in working order. Client records will be stored in a locked closet near the front door.
(Continued on Page 3)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
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

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: A MODERN HOME FOR CARE, LLC	FACILITY NUMBER: 331881532
	VISIT DATE: 06/19/2024

NARRATIVE

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(Continued from Page 2)

First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply and 72-hour emergency food supply was observed. No pool or bodies of water observed. Component III was completed on June 14, 2024 at Riverside RO.

Pre-Licensing is incomplete and the following corrections to be resolved by 6/20/2024:

secure side gate latch

An exit interview was conducted, and a copy of this report was given.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
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

LIC809 (FAS) - (06/04)

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