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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881559
Report Date: 09/23/2024
Date Signed: 09/23/2024 10:36:18 AM

Document Has Been Signed on 09/23/2024 10:36 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:SOC CAREFACILITY NUMBER:
331881559
ADMINISTRATOR/
DIRECTOR:		CARRAWAY, LAQUITAFACILITY TYPE:
735
ADDRESS:644 FIELD MAPLE PLACETELEPHONE:
(951) 665-3489
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY: 3CENSUS: 0DATE:
09/23/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:58 AM
MET WITH:Licensee S'halana CarterTIME VISIT/
INSPECTION COMPLETED:
10:42 AM
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Licensing Program Analysts (LPA's) Armando Perez and Kathleen Banrasavong made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA's met with Applicant, S'halana Carter, who accompanied LPA's for the inspection. The Applicant has submitted an application for three(3) ambulatory 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 3 client bedrooms, 2 bathrooms, laundry room, living room, dining area, kitchen and attached garage. LPA's 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 a shower and clean appliances that were operating in safe and sanitary condition. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Knives and sharps are stored and locked in a kitchen cabinet. Facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Emergency food will be stored in the closet located before the entrance of the garage.

Client and staff files will be in locked cabinet in the Garage. 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 an umbrella and seating for all the clients. All passageways were free from obstruction. LPA's observed 2 charged fire extinguishers in the facility with last service dates of 04/08/24. The smoke detectors and carbon monoxide alarms were tested and operational. The facility does not have any known firearms and ammunition on the property. LPA's observed the required postings of the emergency disaster plan, resident personal rights, complaint procedures, employee rights, visitation rights and facility sketch. LPA's observed the licensees valid Administrator Certification with expiration date of 01/28/2026 and CPR certification expiring on 01/06/2025. Facility contains emergency supplies and first aid kits with the required items. The facility has working telephone for client use.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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: SOC CARE
FACILITY NUMBER: 331881559
VISIT DATE: 09/23/2024
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LPA's 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 9-10-2024. LPA's 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 applicant, S’halana Carter.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC809 (FAS) - (06/04)
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