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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881549
Report Date: 10/14/2024
Date Signed: 10/14/2024 01:16:57 PM

Document Has Been Signed on 10/14/2024 01:16 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:MENIFEE ASSISTED LIVING LLCFACILITY NUMBER:
331881549
ADMINISTRATOR/
DIRECTOR:		ROPER, KARENFACILITY TYPE:
740
ADDRESS:29620 BRADLEY RDTELEPHONE:
(951) 679-3355
CITY:MENIFEESTATE: CAZIP CODE:
92586
CAPACITY: 116CENSUS: 91DATE:
10/14/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Karen Roper Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 10/14/24 Licensing Program Analyst (LPA) Javina George made an announced visit to the facility to conduct a prelicensing inspection-Change of Ownership (CHOW) LPA was greeted and granted entry by Executive Director Karen Roper. Karen accompanied LPA on a tour of interior and exterior areas of the facility
The facility is a single story structure consisting of residents age range 60 and above, that will reside in either memory care or assisted living designated building. The facility has an approved hospice waiver for (30), with (28) residents currently receiving hospice services. The Menifee Fire Department issued an approved fire clearance for (20) bedridden ridden, and delayed egress on 2/13/24.

Exterior: There is designated smoking area along the back wall, with a fountain filled with rocks, an outdoor fireplace and grill in the middle of both the assisted living and memory care buildings. The grass was observed to be green and freshly cut. In addition to the shrubbery being maintained.

Interior:
The facility was observed to have the pull cords inside the resident bathrooms as well and bedrooms that were observed to be operable in both buildings.
Memory care (MC): was observed to have a total of 21 bedroom/bathroom combo style rooms. There is a satellite kitchen, dining area, designated area for activities, locked medication room which contains resident charts, and laundry room. The hot water temperature was checked and found to be within regulatory limits measuring 112.2-116.6 degrees Fahrenheit.

Assisted living (AL): This building was observed to have staff offices, locked medication room, main kitchen dining room, and food supply which was sufficient (2 day of perishable and a 7 day supply of nonperishable food items). Conference room, salon, activities room, laundry room, front lobby/living room. The hot water temperature was checked and measured at 105.8-111.8 degrees Fahrenheit. The facility was observed to be clean and clutter free, there were some visible stains on the carpet throughout the
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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: MENIFEE ASSISTED LIVING LLC
FACILITY NUMBER: 331881549
VISIT DATE: 10/14/2024
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facility in both the assisted living as well as memory care building. The facility is currently remodeling areas throughout the facility and has already had the tile replaced in the main kitchen and carpet inside of some of the resident bedrooms, replaced with wood flooring.

The facility was observed to have fully charged fire extinguishers which were serviced on 2/23/24. The smoke and carbon monoxide detectors were observed to be operable and were last services on 10/3/24-Carbon monoxide and 10/4/24-Smoke detectors. There are no known guns or ammunition on the premises. The facility does not have any pools or bodies of water. The facility had the required postings, and an adequate amount of personal protective equipment (PPE) supplies. The facility was observed to have liability insurance which needs to be renewed before 10/18/24.

The facility has an ample amount of activities available for residents in care and to promote socialization. The facility posts the individual activities outside of the resident bedrooms and has a enlarged activities calendar posted in both buildings for residents to see.

Based on today's inspection the facility the facility is ready for licensure.

An exit interview was conducted and a copy of this report was reviewed and provided to Karen Roper, Executive Director.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC809 (FAS) - (06/04)
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