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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530171
Report Date: 10/04/2024
Date Signed: 10/04/2024 10:40:06 AM

Document Has Been Signed on 10/04/2024 10:40 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
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: 109DATE:
10/04/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Rose YousefianTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analysts (LPAs) Paola Guerrero and Beena Singh conducted an announced pre-licensing visit to the facility. LPAs met with Facility Administrator Rose Yousefian. The pending application is for a Residential Care Facility for Elderly (RCFE). Capacity is (85) and current Census(109). The Administrator accompanied LPAs 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. LPAs observed an in-ground pool at the facility, the perimeter of the pool was gated and locked. LPAs inspected bedrooms all bedrooms were 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. LPAs observed food storage and preparation areas to be clean and sanitary. LPAs inspected facilities freezer along with refrigerators logs all logs displayed appropriate temperatures according to Title 22 regulation. All appliances are clean and operating properly. The outdoor space is suitable for residents use. LPAs observed fully charged fire extinguishers present in the facility. Smoke alarms and carbon monoxide are present and functional. Facility has a designated area (2nd floor 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.

Pre-licensing inspection is complete, and no corrections are needed to be made. Comp III presentation was completed.

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: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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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