<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530171
Report Date: 04/24/2024
Date Signed: 04/24/2024 01:00:36 PM

Document Has Been Signed on 04/24/2024 01:00 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WILDOMAR SENIOR ASSISTED LIVINGFACILITY NUMBER:
335530171
ADMINISTRATOR/
DIRECTOR:
YOUSEFIAN, ROSEFACILITY TYPE:
740
ADDRESS:32365 SOUTH PASADENA STTELEPHONE:
(323) 902-6000
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY: 200CENSUS: 85DATE:
04/24/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Rose YousefianTIME VISIT/
INSPECTION COMPLETED:
01:15 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 Analysts (LPA) Paola Guerrero conducted an announced pre-licensing visit to the facility. LPA met with Facility Administrator Rose Yousefian. The pending application is for a Residential Care Facility for Elderly (RCFE). Current capacity is (85). The Administrator accompanied LPA on a tour of the inside and outside of the facility. The physical plant, in general, was in good repair. The buildings and grounds are free from hazards. The indoor and outdoor passageways are free of obstruction. LPA observed an in-ground pool at the facility, the perimeter of the pool was gated and locked. All bedrooms are furnished with a bed, nightstand, dresser, and chair. All bedrooms have adequate lighting for resident use. Bathroom's toilet, shower and tubs are in good repair and have non-skid mats. LPA observed food storage and preparation areas to be clean and sanitary. LPA inspected facilities freezer and Refrigerators logs all listed appropriate temperatures according to Title 22 regulation. All appliances are clean and operating properly. The outdoor space is suitable for residents use. LPA observed fully charged fire extinguishers present in the facility. Smoke alarms and carbon monoxide are present and functional. Facility has a designated area (Med-Room) where medications are locked and stored. The facility had a designated area where staff and resident records are stored. Emergency disaster plans, personal rights, and complaint posters were posted in a common area. There is adequate seating in the common areas. Facility had a supply of activities for the residents. During review of records LPA found that the facility has yet to complete an updated plan of operation, admission agreement, along with an updated facility sketch that indicates that the facility pool is not owned or part of the facility plan as indicated by the Facility Administrator. On April 24,2024 LPA observed that the facility is still promoting the pool as an amenity through their facilities website. In addition, residents records still listed swimming as part as facilities activities. Pre-licensing inspection is not complete, and doesn't meet the requirement to pass the inspection. LPA will initiate a second inspection when the facility completes the necessary requirements as stated.

An exit interview was conducted, and a copy of this report was provided to Facility Administrator Rose Yousefian.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1