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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403110
Report Date: 09/17/2024
Date Signed: 09/17/2024 05:00:49 PM

Document Has Been Signed on 09/17/2024 05:00 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SLB INCORPORATED-LYDIA'S HOMEFACILITY NUMBER:
336403110
ADMINISTRATOR/
DIRECTOR:		ELLEN AMANTEFACILITY TYPE:
735
ADDRESS:12871 VELVET LEAF ST.TELEPHONE:
(951) 243-7507
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 6DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Administrator Michael HallTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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On 9/17/24 Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced one (1) year required visit. LPA was granted entry by caregiver, Mikko Galang, who was informed of the purpose of visit. At the time of the visit there were three (3) staff, Administrator and six (6) residents present. All staff present were observed to have obtained proper fingerprint clearance and were associated to the facility. LPA Flores observed the following during today's visit:

LPA Flores conducted a tour of the facility with caregiver, Mikko Galang. The physical plant contained four (4) resident bedrooms, two (2) staff bedroom, and two (2) bathrooms. The facility has two (2) formal dining rooms, kitchen, living room, great room, garage, and a gated backyard. Indoor and outdoor passageways were free of obstruction. There were no bodies of water located on the property. The facility has more than a two (2) day supply of perishable food and seven (7) day supply of non-perishable foods. Water temperature measured at 111.3-degree Fahrenheit meeting within the required limits. Dishes and utensils were in sufficient supply and in good repair. Knives and sharp items are located in the kitchen in a locked cabinet underneath the kitchen sink. Resident bedrooms had the required bedding, furniture, and lighting. Disinfectants and cleaning solutions were secured in a locked cabinet in the kitchen. The smoke and carbon monoxide detectors were tested and were observed to be operable. Centrally stored medication was observed in a locked cabinet in the kitchen.



Continuation on LIC809C...
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SLB INCORPORATED-LYDIA'S HOME
FACILITY NUMBER: 336403110
VISIT DATE: 09/17/2024
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Staff files reviewed have a personnel record, health screening, criminal record clearance, required training, valid CPI, and valid first aid/CPR certification. Resident files included but are not limited to signed admission agreements, placement, personal rights, current IPP, and updated physician reports. Facility sketch, LTCO, CCL complaint poster, and emergency disaster plan is posted on a wall near the entrance. Medication Administration Record (MAR) was reviewed for all residents in care and showed no discrepancies. According to Administrator, Michael, there are no firearms or ammunition on the premises.

During today's visit, LPA did not observe any immediate violations or concerns. An exit interview was conducted, and a copy of this report was reviewed and provided to the Administrator, Michael Hall.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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