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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881564
Report Date: 10/30/2024
Date Signed: 10/30/2024 02:11:23 PM

Document Has Been Signed on 10/30/2024 02:11 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:NEW HOPE FACILITY HOME LLCFACILITY NUMBER:
331881564
ADMINISTRATOR/
DIRECTOR:		GIRON, ELIZABETHFACILITY TYPE:
735
ADDRESS:23896 GAMMA STTELEPHONE:
(951) 660-5585
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 0DATE:
10/30/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Elizabeth GironTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Licensing Program Analysts (LPAs), Abdoulaye Zerbo and Armando Perez conducted an announced pre-licensing inspection at the facility and met with Applicant, Elizabeth Giron

Application: The inspection is a change of ownership (CHOW) for an Adult Residential Facility (ARF) application. The Riverside County Fire Department approved a fire clearance for Five (5) non-ambulatory and one (1) ambulatory clients on March 29-2024.

Buildings and Grounds: The home is a single-story building composed of two (2) client bedrooms, 1 staff bedroom, one (1) room for storage only, and one(1) room for isolation in the event of sickness, a living room area, two (2) bathrooms, a laundry room, kitchen and dining area, a garage, and front and back yard. The interior and exterior walkways of the home were observed to be clutter free with no obstructions. Smoke and Carbon Monoxide detectors are hard wired and in working order. There is no gated pool and 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. The facility has a working phone witnessed by calling the phone number.

Storage and Supplies: Medications will be stored in a locked cabinet next to the living room, inaccessible to any unauthorized individuals. Secured locked cabinets in the living room 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 under the kitchen sink. Linens, and equipment appeared to be in good repair and sufficient for the approved census. Fire extinguishers were available and fully charged with an expiration date of 07-16-2025.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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: NEW HOPE FACILITY HOME LLC
FACILITY NUMBER: 331881564
VISIT DATE: 10/30/2024
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Forms: The following signs were observed to be posted at the home: Personal Rights, Complaint information, Emergency disaster plan, the facility sketch, ombudsman's poster. LPAs verified the Administrator's Certification, with an expiration date of September 21, 2025 and CPR certification with the expiration date of May 22, 2026.

LPAs observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. The applicant has completed COMP III orientation on June 14,2024. LPAs determined the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete and has satisfied all requirements in accordance with Title 22, California Code of Regulations. An exit interview was conducted, and a copy of this report was discussed and provided to licensee Elizabeth Giron.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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