335530190-1-30-2024-56-AS-RGAR-CZYSEX-20240130124929

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530190
Report Date: 01/30/2024
Date Signed: 01/30/2024 12:49:34 PM

Document Has Been Signed on 01/30/2024 12:49 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:	EVERLAST ASSISTED LIVING LLC		FACILITY NUMBER:	335530190
ADMINISTRATOR:	LANGI, SOPHEAREAK		FACILITY TYPE:	740
ADDRESS:	30045 AUDELO ST		TELEPHONE:	(951) 579-1120
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92530
CAPACITY:	5	CENSUS: 0	DATE:	01/30/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Sopheareak Langi- Administrator		TIME COMPLETED:	01:00 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) Ryan Gardner conducted an announced visit to complete the Pre-licensing inspection. LPA met with Administrator Sopheareak Langi for a Residential Care Facility for the Elderly (RCFE) for five (5) non-ambulatory residents, one (1) resident may be bedridden. The fire clearance was approved by the fire department on 11/28/2023. The facility has four (4) bedrooms and two (2) bathrooms. There are four (4) resident bedrooms, two (2) resident bathrooms, a kitchen, a living room, a dining area, a laundry room, a backyard, and an attached garage. LPA toured the interior and exterior areas of the facility. The following were inspected: Resident Bedrooms: All bedrooms have the required bedding and furniture, such as clean mattresses/linens, mattress covers, nightstands, dressers, chairs, and lighting. Resident Bathrooms: The bathrooms appliances were operating in safe and sanitary condition. The water temperature was measured by LPA, the thermometer read at 117.8 degrees F. Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for resident use. Kitchen appliances and countertops were free of debris and in good repair. The refrigerator was measured at 40 degrees F and the freezer was measured at 0 degrees F. The chemicals were locked underneath the kitchen sink. The sharps were locked in the kitchen cabinet. Medication: The location for medications was locked and secured in the hallway closet. Common Sitting Areas/Activities: There is adequate seating in the common areas for the residents. The facility has a supply of activities for the residents.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EVERLAST ASSISTED LIVING LLC	FACILITY NUMBER: 335530190
	VISIT DATE: 01/30/2024

NARRATIVE

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Laundry Room/Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies were available for each resident. The laundry room contains chemicals and was securely locked.

Backyard: There are no bodies of water in the backyard. There is a covered area with seating for the all the residents. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There are two (2) charged fire extinguishers in the facility. LPA observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and or ammunition.

Postings: LPA observed required postings including the visitation polices, emergency/disaster plans, complaint procedures, labor laws, and personal rights.

First aid and working telephone: The facility is equipped with a complete first aid kit and manual. The facility has a working telephone for resident use.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA has determined that the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete, and the facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations.

The required Comp III presentation was completed. An exit interview was conducted, and this report was discussed and provided to Administrator Sopheareak Langi.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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