331881537-7-17-2024-18-AS-JGEE-D79NGZ-20240717102758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881537
Report Date: 07/17/2024
Date Signed: 07/17/2024 10:28:05 AM

Document Has Been Signed on 07/17/2024 10:28 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:	CANYON CREST ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	331881537
ADMINISTRATOR:	CHOUDRY, SAHER		FACILITY TYPE:	740
ADDRESS:	5005 WESTMONT ST		TELEPHONE:	(951) 522-1425
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92507
CAPACITY:	6	CENSUS: 0	DATE:	07/17/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Saher Choudry		TIME COMPLETED:	10:30 AM

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 7/17/24 Licensing Program Analyst (LPA) Javina George made an announced visit to the facility for the purpose of conducting a prelicensing inspection. LPA met with Applicant/Administrator Saher Choudry, whom accompanied LPA for the inspection. The Applicant has submitted an application for 6 residents (5 non ambulatory and 1 bedridden). On 1/5/24 the Riverside County Fire Department approved a fire clearance for which the applicant has applied for. The master bedroom, (bedroom #2), is specifically for a bedridden resident and rooms 1, 3 and 4 are for non ambulatory residents. The facility has an approved hospice waiver for three (3). The home is a single story structure consisting of (4) bedrooms, (3) bathrooms, kitchen, formal dining room, family room, garage, backyard with a covered patio, locked and fenced pool and jacuzzi, and a shed that is being used for storage. The facility is utilizing video surveillance on the exterior areas of the home. 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 within regulatory limits measuring at 118.4 degrees Fahrenheit. The facility is equipped with flash lights, night lights and solar panels. 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 passageways, and ramps/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 kept in individual

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

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: CANYON CREST ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 331881537
	VISIT DATE: 07/17/2024

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boxes, that will stored in a locked cabinet below/next to the kitchen sink.

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 he Long term Care Ombudsman poster were observed to be posted.

The facility was observed to have activities to encourage socialization such as, coloring books, books dice game as well as a covered patio with plenty of outdoor space for walking and a basketball court.

The applicant successfully completed COMP III orientation on 4/25/24.

Based on today's inspection it is the recommendation that the home be licensed once the following is completed:
-Liability insurance (pending license number)

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

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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