331881570-6-27-2024-18-AS-YDEO-D6MH4Q-20240627055216

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881570
Report Date: 06/19/2024
Date Signed: 06/27/2024 05:52:33 AM

Document Has Been Signed on 06/27/2024 05:52 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	VKARE RESIDENTIAL ASSISTED LIVING HOME		FACILITY NUMBER:	331881570
ADMINISTRATOR:	BALAJI ,VIJETHAA; THIRUMAL		FACILITY TYPE:	740
ADDRESS:	9509 ESTRELLA HILLS STREET		TELEPHONE:	(310) 218-3056
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92508
CAPACITY:	4	CENSUS: 0	DATE:	06/19/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Balaji Thirumalai & Vijethaa Balaji, Licensees		TIME COMPLETED:	03:15 PM

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	Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 1:00 PM, LPA met with Licensees Balaji Thirumalai & Vijethaa Balaji. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 2/11/2024 for a total capacity of four (4) , two (2) non-ambulatory and two (2) bedridden residents. Fire clearance was granted on 04/18/2024. LPA Delgado observed the following: Structure: Facility was a two-story house with two (2) resident bedrooms-shared, one and half (1.5) resident bathrooms, living room, family room, dining area and kitchen. There was an attached two car garage in the front of the house. Upstairs has 5 rooms and 3 bathrooms that will be occupied by the Licensee, not by any residents. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located on the first floor hallway to control entire house. Bedrooms: Each resident bedroom #6 will accommodate 2 non-ambulatory residents, bedroom #7 will accommodate 2 bedridden residents. Resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VKARE RESIDENTIAL ASSISTED LIVING HOME	FACILITY NUMBER: 331881570
	VISIT DATE: 06/19/2024

NARRATIVE

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Bathrooms:
One and a half (1.5) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 1:40 PM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 115.9 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked closet located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located on the 2nd floor. Laundry detergents will be stored upstairs in the laundry room and cleaning supplies were observed in garage away from residents.
Living/Family room:
There was a living/family room with sufficient furniture for all clients and a TV in the family room.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a closet on the first floor and hygiene in the garage.
Yards/Outside:
Patio table and chairs were observed in the backyard with umbrella. There was a gate on the South side with a self-latch. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted at the designated exits of the home. Obudsman poster, non-discrimination notice, resident's rights and Let-Us-No poster observed.

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SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VKARE RESIDENTIAL ASSISTED LIVING HOME	FACILITY NUMBER: 331881570
	VISIT DATE: 06/19/2024

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General items:
One (1) fire extinguisher were charged and located in the kitchen. Seven (7) smoke alarms and two (2) carbon monoxide detectors were tested and were observed to be in working order. Residents records will be stored in a locked cabinet in the Living room. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply was not observed however the required 72-hour emergency food supply was not discernible from the regular food supply. No pool or bodies of water observed. Component III was completed on June 14, 2024 at Riverside RO.

Pre-Licensing is incomplete and the following corrections to be resolved by 6/24/2024:

obtain a separate 72-hour emergency food supply
obtain separate emergency water
obtain trash cans with lids for bathrooms

An exit interview was conducted, and a copy of this report was given.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

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