336402994-7-28-2023-56-AS-MMAE-CU6QSS-20230728122601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336402994
Report Date: 07/28/2023
Date Signed: 07/28/2023 12:26:05 PM

Document Has Been Signed on 07/28/2023 12:26 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:	LIFESTYLE HOME CARE		FACILITY NUMBER:	336402994
ADMINISTRATOR:	MARY MATEAS		FACILITY TYPE:	740
ADDRESS:	5377 CAROL WAY		TELEPHONE:	(951) 684-5833
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY:	6	CENSUS: 3	DATE:	07/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Mary Mateas, Administrator		TIME COMPLETED:	12:30 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) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Mary Mateas, Administrator and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) non-ambulatory resjdents and a current census of (3). Hospice waiver for (2). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Facility has no outdoor bodies of water. Facility has furniture in good repair for residents in care. Facility has a covered outdoor area and gated front and back yard. LPA inspected the kitchen. The refrigerator temperature is maintained at 40 degrees F. Hot water temperature is maintained at 112 degrees F. Facility has sufficient non-perishable and perishable food supply for the number of residents in care. A monthly menu is posted in the kitchen. Facility has sufficient cups, plates, and utensils for residents in care. Facility food is stored in a safe and healthful manner. LPA inspected client bedrooms. Bedrooms are equipped with mattresses, nightstands, pillows, chairs, and storage space. Bedrooms have sufficient linen and lighting.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LIFESTYLE HOME CARE	FACILITY NUMBER: 336402994
	VISIT DATE: 07/28/2023

NARRATIVE

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LPA inspected client bathrooms. Bathrooms are equipped with handrails and operating in safe and sanitary conditions. Bathrooms hot water temperature is maintained at 105 degrees and 110 degrees F.

LPA observed the facility is equipped with operating carbon monoxide alarms and fully charged fire extinguisher. Facility has operating telephone service on the premises. Posters such as personal rights, Licensing complaint contact number, Ombudsman contact number, emergency phone numbers are posted in a common area. Emergency drill was conducted on 7/06/23. Disinfectants, cleaning solutions, and toxins are kept locked and inaccessible to residents in care. Sharps are kept locked and inaccessible to residents in care.

Client medications are kept in a safe and locked cabinet inaccessible to clients in care. All medication are labeled and administered as prescribed.

All staff files reviewed had First Aid Certifications, fingerprint clearances/exemptions, health screenings, training, employee applications.

All client records reviewed had admissions agreements, medical assessment, needs service plans, record of personal property.

Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. No deficiencies were cited during today's visit.

An exit interview was conducted, where this report (LIC809) was discussed and a copy of report with appeal rights was provided to the Administrator at the conclusion of the visit

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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