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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403110
Report Date: 09/22/2023
Date Signed: 09/22/2023 10:52:23 AM

Document Has Been Signed on 09/22/2023 10:52 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:SLB INCORPORATED-LYDIA'S HOMEFACILITY NUMBER:
336403110
ADMINISTRATOR:ELLEN AMANTEFACILITY TYPE:
735
ADDRESS:12871 VELVET LEAF ST.TELEPHONE:
(951) 243-7507
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 6DATE:
09/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:CEO Michael A. HallTIME COMPLETED:
11:00 AM
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On 9/22/2023, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Caregiver Hazel Galang who was informed of the purpose of the visit. CEO Michael A. Hall arrived during the visit.

During the visit, there was two (2) staff present, and LPA was informed that six (6) clients were at day program. LPA toured the facility’s interior and exterior with Caregiver Galang. During the tour, LPA observed the following:

The facility is made up of four (4) client bedrooms, two (2) client bathrooms, two (2) staff rooms, two (2) living rooms, a kitchen, dining room and garage. LPA observed the facility was very clean and free of foul odors. Client bedrooms were clean and each furnished with a bed, chair, closet, clothing storage and lighting. LPA toured the kitchen and observed the facility had more than a 2-day supply of perishable food items and 7-day supply of non-perishable food items. Cleaning solutions and knives were secured in a cabinet under the kitchen sink.

Bathrooms have a working toilet, wash basin, and were equipped with nonskid mats in the shower. The hot water temperature measured at 115- and 116-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the clients in care. Washing machine and dryer are in good repair and stored in the garage. Incontinent supplies and backpacks filled with emergency kits were also stored in the garage.

Continued on LIC809-C.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: SLB INCORPORATED-LYDIA'S HOME
FACILITY NUMBER: 336403110
VISIT DATE: 09/22/2023
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Continued from LIC809.

LPA observed a first aid kit with required components. Medications were secured in a kitchen cabinet. LPA reviewed physical medications for three (3) clients as well as the Medication Administration Record (MAR) used to log administration of clients’ medications. No discrepancies discovered. LPA reviewed three (3) client files, which had updated physician's reports, Individual Program Plans, and physical assessments. Staff present have a criminal background clearance, are associated to the facility and have current CPR/First Aid certification. LPA reviewed the Record of Client's/Resident's Safeguarded Cash Resources (LIC405) for three (3) clients along with their physical money and did not discover any discrepancies.

LPA tested the smoke and carbon monoxide detectors and found them to be operational. The facility's fire extinguishers were last serviced on 3/3/2023. LPA observed fire alarms throughout the facility. The facility's last earthquake drill was conducted on 9/9/2023 and fire drill on 9/10/2023.

Indoor and 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.

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 CEO Hall.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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