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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530052
Report Date: 12/04/2023
Date Signed: 12/04/2023 10:58:15 AM

Document Has Been Signed on 12/04/2023 10:58 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
, CA 92507
FACILITY NAME:MESA POINTE HOMEFACILITY NUMBER:
335530052
ADMINISTRATOR:CARMEN D. WYDERMYREFACILITY TYPE:
735
ADDRESS:171 TRADITION COURTTELEPHONE:
(951) 452-4565
CITY:CALIMESASTATE: CAZIP CODE:
92320
CAPACITY: 4CENSUS: 3DATE:
12/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Gloria Thomas-Licensee TIME COMPLETED:
11:15 AM
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Licensing Program Analyst LPA Bernadette Allen made an unannounced visit to the facility to conduct a required annual inspection. LPA arrived at 8:40 AM rang the doorbell there was no answer. LPA called the mobile number on file and Gloria was informed that LPA Allen was at the facility to conduct the annual inspection. Gloria stated that she would come to the facility, but it will take her about 15 minutes to arrive. Gloria Thomas arrived at 9:05am and informed LPA that staff were not at the home and the residents were at day program. .

The facility has four(4) bedrooms and two (2), bathrooms, kitchen/dining area, living room, and attached garage. The facility is an Adult Residential Facility (ARF) level 3N home vendored by Inland Regional Center Licensed capacity is (4) current census (3).LPA conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected clients bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately.

LPA observed sufficient furniture and lighting throughout the facility.LPA measured and observed the water temperatures in the bathrooms to be at 105.7 -120 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide detectors and fully charged fire extinguishers. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in the common area.

Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside the closet in the main entrance area. Overall, the facility is clean, in good repair, and operates in safe conditions for clients in care.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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
, CA 92507
FACILITY NAME: MESA POINTE HOME
FACILITY NUMBER: 335530052
VISIT DATE: 12/04/2023
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Food Service: Non-perishable and perishable food supply is sufficient for the number of clients in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans.

LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

Medications were audited at random and appeared to be dispensed appropriately by staff members. PNI funds were counted for and matched with the ledger.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Gloria Thomas at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
LIC809 (FAS) - (06/04)
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