335530153-11-1-2023-56-AS-AGOG-CX6TC3-20231101143606

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530153
Report Date: 11/01/2023
Date Signed: 11/01/2023 02:41:21 PM

Document Has Been Signed on 11/01/2023 02:41 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
, CA 92507

FACILITY NAME:	AFFINITY ASSISTED LIVING		FACILITY NUMBER:	335530153
ADMINISTRATOR:	CONCHA, JADE CELLENE		FACILITY TYPE:	740
ADDRESS:	12730 CASTLE ROAD		TELEPHONE:	3104655022
CITY:	EASTVALE	STATE: CA	ZIP CODE:	92880
CAPACITY:	6	CENSUS: 0	DATE:	11/01/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jade Concha, Admiistrator Lauren Malapitan, Administrator Jehmari Concha, CEO		TIME COMPLETED:	03:00 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	Licensing Program Analyst (LPA) Amy Goldenberg conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate a Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 06/20/2023 for a total capacity of 5 non-ambulatory and one bedridden resident. Fire Clearance was granted 07/19/2023. LPA Goldenberg observed the following: Structure: Facility was a single story house with four (4) resident bedrooms, two and one half bathrooms, living room, dining area, and kitchen area. Heating/Cooling System: Central heating and air conditioning systems. Bedrooms: All bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by LPA and thermometer read by LPA at 118 F. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

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: AFFINITY ASSISTED LIVING	FACILITY NUMBER: 335530153
	VISIT DATE: 11/01/2023

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Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.

Yards/Outside: The back was completed was a patio with adequate covered area for providing shade. There were no obstructions. There were no bodies of water observed anywhere on the property.

Garage: Garage was organized and free of obstructions.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster and clients rights are posted.

General items: The facility has smoke and carbon monoxide detectors. These were tested and remain operational. LPA observed a facility phone and it was verified to be operational by LPA.

COMPONENT III with the applicant was conducted during this Pre Licensing Inspection.

This facility physical plant is prepared for licensure at this time. A copy of this report was reviewed with and provided to the applicant.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC809 (FAS) - (06/04)

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