331881703-4-10-2025-18-AS-JARA-DF7SHW-20250328135412

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881703
Report Date: 03/28/2025
Date Signed: 04/10/2025 03:27:20 PM

Document Has Been Signed on 04/10/2025 03:27 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:	EXTRAORDINARY LIVING GP		FACILITY NUMBER:	331881703
ADMINISTRATOR/ DIRECTOR:	PARKER, JACQUIECE		FACILITY TYPE:	735
ADDRESS:	4372 ALMATERRA DRIVE		TELEPHONE:	(562) 235-7456
CITY:	PERRIS	STATE: CA	ZIP CODE:	92571
CAPACITY: 4		CENSUS: 0	DATE:	03/28/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Applicants, Jacquiece and Brittney Parker		TIME VISIT/ INSPECTION COMPLETED:	02:00 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	The following is an amended report: Licensing Program Analyst (LPA) Janira Arreola, conducted an announced visit for the purpose of conducting the prelicensing inspection. LPA met with Applicants, Jacquiece and Brittney Parker. The applicant is seeking an initial application for an adult residential facility with a capacity for (4) residents, ages 18 to 59 years old. LPA conducted a walk through of the interior and exterior of the facility. The home is a (3) bedroom and (2) bathroom, one story home with attached garage. The fire clearance conducted by the local fire jurisdiction and approved for (4) non-ambulatory residents. LPA observed the rooms had the appropriate linens, furniture such as bed, dresser, closet space, light, night stand and chair. The home has extra linens and bath towels. Locked medication storage will be kept in the kitchen. Emergency supplies such as first aid kit with all requirement items were observed. The facility kitchen has enough pots and pans, cooking utensils, plates and cups. The kitchen had the appropriate food items. LPA observed the bathrooms in the facility to have hand hygiene supplies, and personal care items for future residents. The laundry room was observed be functional, and the facility possesses cleaning supplies to conduct regular cleaning of the facility. Cleaning products will be kept in locked areas of the home.

NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: EXTRAORDINARY LIVING GP	FACILITY NUMBER: 331881703
	VISIT DATE: 03/28/2025

NARRATIVE

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The smoke alarms and carbon monoxide detectors were found in working condition. The dining room has enough seating for (4) residents, and the outdoor space has enough seating for (4) residents with shade and emergency exit. LPA observed the home has activities for clients to engage in. No bodies of water or firearms are being kept in the facility. Kitchen knifes will be kept locked with the in the kitchen. The hot water temperature was recorded in the kitchen sink at 119F during the time of the visit.

LPA observed the home had a landline telephone, with schedule service date of April 2, 2025. The applicant stated they would provide the phone number and inform of the service completion before being licensed. An exit interview was conducted were this report was reviewed and provided to the applicants.

NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/10/2025 03:25 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/10/2025 03:21 PM

Created By: Janira Arreola On 03/28/2025 at 01:40 PM

Link to Parent Document Below:

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: EXTRAORDINARY LIVING GP	FACILITY NUMBER: 331881703
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	Based on observation and interview the applicant did not have telephone service at the time of the visit. The applicant stated they would obatin phone services and provide proof to the LPA. The deficency was generated erroneously and the applicant has since completed the correction.
	POC Due Date:
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4	Based on observation and interview the water in the home exceeded 120F, but was later corrected at the end of the visit when the applicant adjusted the water heater. The deficency was generated erroneously and the applicant has since completed the correction.
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Tricia Danielson
NAME OF LICENSING PROGRAM MANAGER:

	Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

LIC809 (FAS) - (06/04)

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