336402301-7-30-2023-18-AS-JROO-CU8MWS-20230730095850

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336402301
Report Date: 07/30/2023
Date Signed: 07/30/2023 09:58:54 AM

Document Has Been Signed on 07/30/2023 09:58 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	HAZEL GUEST HOME		FACILITY NUMBER:	336402301
ADMINISTRATOR:	HAZEL ABELLA		FACILITY TYPE:	740
ADDRESS:	24641 SUPERIOR AVENUE		TELEPHONE:	(951) 601-0689
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92551
CAPACITY:	6	CENSUS: 4	DATE:	07/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator Hazel Abella		TIME COMPLETED:	10:15 AM

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On 7/30/2023, at 8:30 a.m., Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Ronniel De Jesus who was informed of the purpose of visit. Administrator Hazel Abella was at the facility during the visit. The facility is approved for 6 non-ambulatory residents. During the visit, there was four (4) residents and (2) staff present.

LPA toured the facility’s interior and exterior with Administrator Abella. During the visit, LPA observed the following:

Kitchen: LPA observed kitchen area to be clean. Food is stored in a safe and healthful manner. LPA observed the facility had a 2-day supply of perishable foods and 7-day of non-perishable food items. Knives/sharp instruments are secured in a locked cabinet under the kitchen sink.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. LPA observed residents sitting in the living room watching television.

Hallway: LPA observed hallway to be clean with no pathway obstruction. Facility has a fire alarm system. Carbon monoxide & smoke detectors were tested and functioning properly.

Continued on LIC809-C..

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2023

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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HAZEL GUEST HOME	FACILITY NUMBER: 336402301
	VISIT DATE: 07/30/2023

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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a kitchen cabinet. LPA reviewed physical medications for the residents as well as Medication Administration Record, no discrepancies discovered.

Bedrooms: Resident bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathroom has a working toilet, wash basin, and were equipped with a grab bar in the shower. The hot water temperature measured at 105-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the residents in care.

Laundry/Garage: LPA toured the laundry room and garage. Washing machine and dryer are in good repair. Cleaning solutions and chemicals are secured in locked laundry room. Emergency food supplies, water, additional hygiene supplies, linen and towels are stored in the garage.

Records: Staff present have a criminal record clearance on file and are associated to the facility. Staff training is up to date.

Yard/Outside Area: Shaded seating area in the backyard is available for the residents to sit and relax. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

Residents’ Cash Resources: The facility safeguards residents’ cash resources. LPA reviewed Record of Client’s/Resident’s Safeguarded Cash Resources (LIC) 405 for all residents along with residents' cash, and did not discover any discrepancies.

During today’s visit, LPA did not observe any deficiencies. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Abella.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2023

LIC809 (FAS) - (06/04)

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