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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881543
Report Date: 07/29/2024
Date Signed: 07/29/2024 09:42:42 AM

Document Has Been Signed on 07/29/2024 09:42 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:UNITED IN CHANGE - AVENIDA HOUSEFACILITY NUMBER:
331881543
ADMINISTRATOR/
DIRECTOR:		MONTGOMERY, MONICAFACILITY TYPE:
735
ADDRESS:26452 AVENIDA DE LA PAZTELEPHONE:
(951) 498-1770
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 0DATE:
07/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Etta Simpson, ApplicantTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an announced pre-licensing inspection at the home and met with Applicant, Etta Simpson.

Application: The inspection is for an initial Adult Residential Facility (ARF) application. The fire clearance has been granted for four (4) ambulatory clients.

Buildings and Grounds: The home is composed of four (3) client bedrooms, one (1) staff bedroom/office, two (2) living room areas, three (3) bathrooms, a laundry room, kitchen, one (1) dining area, 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. There are no weapons stored in the home. Client bedrooms are fully furnished, and privacy is available. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer were available and in working order.

Storage and Supplies: Medications will be stored in a locked cabinet, 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 freezer are in working order. Sharps will be stored in a locked area, available only to authorized individuals.

Forms: The following signs were observed to be posted at the home: Personal Rights, Complaint information
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2024
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 3
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: UNITED IN CHANGE - AVENIDA HOUSE
FACILITY NUMBER: 331881543
VISIT DATE: 07/29/2024
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and the Facility Sketch (LIC 999).

Corrections: The LPA observed the backyard not to be maintained in a proper manner; LPA observed the grass to be completely dried out, metal items like an animal crate and a bed frame to be blocking holes in the fence on both sides of the yard, rocks and bricks covering holes under the fence, a warn animal house and grill to be stored near the walk way, animal toys and other debris lying in the backyard, dog feces in the backyard, exercise and other equipment improperly stored in the backyard. LPA observed personal items throughout the home; LPA observed two (2) of three (3) client bedrooms to be occupied by individuals currently living in the home. LPA observed the hall bathroom to require cleaning, such as sweeping and moping, LPA observed one drawer in one client bedroom to be broken, as the drawers were shifted and sticking out. LPA observed the closet drawers in the same bedroom to not be flush with the floor and were not hanging straight.

Another inspection may be required prior to the applicant obtaining a license. The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensing once corrections are completed. This report was discussed with, and a copy provided to Applicant Simpson.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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