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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881683
Report Date: 02/10/2025
Date Signed: 02/10/2025 10:16:25 AM

Document Has Been Signed on 02/10/2025 10:16 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:POLARIS RESIDENCESFACILITY NUMBER:
331881683
ADMINISTRATOR/
DIRECTOR:		AIKMAN, MELLANIEFACILITY TYPE:
735
ADDRESS:28903 CATTLEMAN CIRCLETELEPHONE:
(562) 353-3724
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY: 4CENSUS: 0DATE:
02/10/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Arminia Zafra and Rossano Zafra, ApplicantsTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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On 02/10/2025 Licensing Program Analyst (LPA) Javina George made an announced visit to the facility to conduct a prelicensing inspection. LPA met with Applicants Arminia Zafra and Rossano Zafra whom accompanied LPA throughout today's inspection. The applicants have applied for a Change of Ownership (CHOW), with no clients in care, age range 18 through 59. On 11/27/24 the Riverside County Fire Department approved the facility for (4) ambulatory Clients.

The facility is single story structure and consisting of (4) bedrooms and (2) bathrooms, kitchen, laundry room, den, dining area, garage, and a backyard with a fire pit, adequate seating and orange trees. The facility was observed to possess solar panels and to utilize video surveillance on the exterior of the property. LPA observed for the home to have the required postings, and operable combined smoke and carbon monoxide detectors, and (1) fully charged fire extinguisher. The facility was observed to have a sufficient food supply of 2 day of perishable and a 7-day supply of nonperishable food items.

The bathrooms are equipped with nonskid mats, and grab bars. The client bedrooms were observed to have adequate lighting, clean linen, chest of drawers, and chairs. The hot water temperature was observed to be within regulatory limits measuring at 112.2-113.3 degrees Fahrenheit. The medications, as well as client and staff files will be stored inside a locked closet located in the hallway/entryway across from the kitchen. The sharps will be stored in a locked drawer located in the kitchen directly in front of the refrigerator. The facility does not have any pools or bodies of water or known guns or ammunition on the premises.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22 Chapter 6, Division 6. The applicants successfully completed COMP III orientation on 1/28/25. Based on the observations and evaluation of the facility this date, the facility’s ready for licensure.

An exit interview was conducted, and a copy of this report was provided to applicants Zafra and Rossano Zafra.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
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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