335530268-2-3-2025-56-AS-MBRN-DDJSF9-20250203124957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530268
Report Date: 02/03/2025
Date Signed: 02/03/2025 12:50:12 PM

Document Has Been Signed on 02/03/2025 12:50 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:	SALVATION RESIDENTIAL CARE		FACILITY NUMBER:	335530268
ADMINISTRATOR/ DIRECTOR:	CAGE, WANDA		FACILITY TYPE:	735
ADDRESS:	22776 SALVATION WAY		TELEPHONE:	(323) 535-8303
CITY:	WILDOMAR	STATE: CA	ZIP CODE:	92595
CAPACITY: 6		CENSUS: 0	DATE:	02/03/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Applicant Philiet Spane and Administrator/Applicant Wanda Cage		TIME VISIT/ INSPECTION 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	On 02/03/2025 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown conducted an announced visit to the facility for the purpose of Prelicensing evaluation. LPA met with Applicant Philiet Spane and Administrator/Applicant Wanda Cage. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 11/05/2024 for a total capacity of six (6) Ambulatory clients. Fire clearance was granted on 10/30/2024. LPA Brown observed the following: Structure: Facility's a one (1) story house with three (3) client bedrooms, one (1) Office Room and two (2) bathrooms, living room, dining area, kitchen, and laundry room. There's an attached two (2) car garage in front of the house. Heating/Cooling System: Central heating and air conditioning system installed with one (1) central panel located in the hallway to control entire house. Bedrooms: Each client bedrooms accommodate any ambulatory client. All client bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, a lamp and an operable smoke/carbon monoxide alarm. Bathrooms: The two (2) client/staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. LPA Brown tested the water temperature in the clients' shared bathrooms and *CONTINUED ON LIC 809-C*

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

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: SALVATION RESIDENTIAL CARE	FACILITY NUMBER: 335530268
	VISIT DATE: 02/03/2025

NARRATIVE

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***CONTINUED FROM LIC 809***
LPA Brown verified water temperature was measured at 112.2 degrees Fahrenheit.

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments
were secured in a locked closet located in the hallway. There was adequate room for food storage. LPA Brown observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There’s an adequate seating for meals for all clients. Laundry room with washer and dryer. Laundry detergents and cleaning supplies were observed in a locked closet in the hallway. Garage will not be accessible to clients.

Living/Family room:
There’s a living/family room with adequate seating for all clients and a working TV.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the staff room.

Yards/Outside:
Patio furniture for outdoor seating was delivered during the visit. Self-latching handle gate on right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan:
No Facility sketch, Personal Rights, House Rules, Visitation Policy, Emergency Disaster Plan observed posted on common areas. No Let-Us-No poster observed. Technical Assistance issued.

General items:
One (1) fire extinguisher charged and located in the kitchen. Combined smoke detectors and carbon monoxide detectors were tested and were observed to be in working order. Client records and staff records will be stored in a locked cabinet located in the staff room. First Aid kit with required components, and locked area for medication storage was observed. However, LPA Brown did not observe First Aid Book maintained at the facility. Technical Assistance issued. ***CONTINUED ON LIC 809-C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

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: SALVATION RESIDENTIAL CARE	FACILITY NUMBER: 335530268
	VISIT DATE: 02/03/2025

NARRATIVE

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***CONTINUED FROM LIC 809***
LPA Brown observed a facility phone and was operational as evidenced of LPA dialing the number. The phone number designated for the facility is 951-226-7160.

There is enough Emergency water observed but no emergency supplies and the required 72-hour emergency food supplies for clients and staffs available at the facility. Component III was completed on this day as well.

Additionally, LPA Brown observed no Visitor Sign In/Sign Out Sheet and Client Sign In/Sign Out Sheet, upon entering facility.

Pre-Licensing is incomplete and the following issued to be resolved by 02/07/2025 at 11:00 AM:

Obtain First Aid Book
Obtain and post Community Care Licensing Division (CCLD) Let-Us-Know poster
Develop Menu
Post Activity Calendar
Post Facility Sketch on common areas
Print and Post House Rules
Print and Post Visitor Policy
Clients & Visitors Sign-in & Sign-out Sheet

A follow up Pre-Licensure LIC809 will be generated upon resolution of the issues observed.

An exit interview was conducted, and a copy of this report, LIC809 was discussed and provided to Applicant Philiet Spane and Administrator/Applicant Wanda Cage.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

LIC809 (FAS) - (06/04)

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