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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881708
Report Date: 03/11/2025
Date Signed: 03/11/2025 12:19:10 PM

Document Has Been Signed on 03/11/2025 12:19 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PERRY'S ADULT FACILITIESFACILITY NUMBER:
331881708
ADMINISTRATOR/
DIRECTOR:		CHIN, PHILLIPPEFACILITY TYPE:
735
ADDRESS:27785 AUBURN LANETELEPHONE:
(951) 253-5288
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 5CENSUS: 3DATE:
03/11/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:28 AM
MET WITH:LEAD CAREGIVER, JUNE CHIN TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On March 11, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct a Pre-Licensing (CHOW), and met with lead Caregiver, June Chin. Facility records were requested and reviewed on site. The facility is licensed for five (5) Adults and is operating currently at a capacity of three (3) Adults (735).
LPA Mixson toured the facility along with Lead Caregiver, June Chin and made observations pertaining to the Pre-Licensing visit.

Physical Plant: The location is a two-story home located at 27785 Auburn LN Moreno Valley, CA. 92555. and has four bedrooms, three full bathrooms, and a half bathroom. A living room, dining room, and a kitchen, with a two-car garage. A backyard and front yard. The Moreno Valley Fire Department approved this facility for five (5) Ambulatory, zero (0)-Non-Ambulatory, and zero (0) bedridden resident, on January 16, 2025. The home has a first aid kit and manual, the Administrator has received First Aid and CPR training, and the Administrator’s certificate is current with an expiration date of 06/20/2025. For Phillippe Chin(87303).



Medications: LPA Mixson observed medications stored, locked, and inaccessible to residents in care. The home is equipped with lights in the passages and stocked with emergency night lights throughout the home. The smoke and carbon monoxide detectors were observed and are operable. LPA Mixson observed the fire extinguisher, it was charged and in the green, and services 02/2025. The cleaning supplies were locked and inaccessible, along with the sharp objects. Lead Caregiver, June Chin informed the LPA there are no firearms on the premises. (87465).
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 4
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: PERRY'S ADULT FACILITIES
FACILITY NUMBER: 331881708
VISIT DATE: 03/11/2025
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Bedrooms: The bedrooms were large enough to allow for easy passage between the beds, and other required items of furniture were present currently at the time of this inspection. Chair, nightstand, and sufficient lighting for future residents. (87307).

Inside/Outside: All doors, and passageways are clear of obstruction. There was a body of water on the premises, it was in the backyard and one in the front yard. They were decorative water fall that may or may not have water during the seasonal rains. Fireplace was covered with a screen and not operable.



There was enough clean linen and hygiene items for residents in care, and extra in case of an emergency. LPA observed appropriate lighting in each resident’s room. LPA Mixson observed central heating and air conditioning systems and they were operable.

Supplies: There is a sufficient supply of clean linen, including blankets, bedspreads top sheets, bottom sheets, pillowcases, mattress pads, bath towels, hand towels, and wash cloths, to permit changing weekly or more often as needed. (87307).

Lead Caregiver dialed the land line phone number (951) 243-5288, and it was operable. Outside/Yards: Had shade and covering for shaded visits, and activities. There were no obstructions or clutter obstructing doorways observed currently.

There were no Title 22, Division 6, Regulations observed or cited during todays vist.

CAB 8.0 Pre-licensing / COMP III Completed 03/11/2025, at the Riverside Spruce Street Office.

An exit interview was conducted, a copy of this report was discussed and given to Lead Caregiver, June Chin.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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