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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881607
Report Date: 11/15/2024
Date Signed: 11/26/2024 08:41:46 AM

Document Has Been Signed on 11/26/2024 08:41 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:HOME OF COMFORT LLC #2FACILITY NUMBER:
331881607
ADMINISTRATOR/
DIRECTOR:
HAWKINS, TASHAFACILITY TYPE:
735
ADDRESS:32916 EARLSBURN CIRTELEPHONE:
(951) 566-5392
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 4CENSUS: 0DATE:
11/15/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Applicant, Tasha HawkinsTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Janira Arreola, made an announced visit to the facility in order to conduct a prelicensing inspection. LPA met with Applicant, Tasha Hawkins.

The facility is seeking an initial application. The facility will be licensed as a adult residential facility, with capacity of (4) ambulatory clients. The facility does not have a pool or firearms. The home is a one story home with (4) bedrooms and (3) bathrooms.

LPA conducted a walk through of the interior and exterior of the facility. The bedrooms have all the required furniture, and required hygiene supplies, and linens. LPA observed the hallway lights and the carbon monoxide detectors were in good working condition. The outdoor area was free of any hazards and had a shaded area for residents and an emergency exit. The kitchen had the ability to prepared food is a clean and safe environment. The kitchen has the required food supplies for future residents. LPA observed areas where the staff and resident files would be kept as well as locked areas designated for medication, sharp objects, and cleaning supplies. The hot water temp was measures at 111.5F. The facility has a land line is operational at (951) 566-5392. Emergency supplies such as water, food, first aide kits were observed during the time of the visit. The required postings were found in the facility.

There are no objections for the applicant to proceed in the prelicensing process. An exit interview was conducted with the applicant, and copy of this report was reviewed and provided to them.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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