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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403573
Report Date: 09/06/2022
Date Signed: 09/06/2022 11:22:43 AM


Document Has Been Signed on 09/06/2022 11:22 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:VILLAGE, THEFACILITY NUMBER:
336403573
ADMINISTRATOR:ROB TAKAMIFACILITY TYPE:
741
ADDRESS:2200 WEST ACACIATELEPHONE:
(951) 766-5116
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY:452CENSUS: 89DATE:
09/06/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jennifer Haas & Griselda T. Garcia - AdministratorsTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of following up on the relocation of residents from Buena Vista Assisted Living (#331880902) to this location due to emergency evacuation orders from a nearby fire. LPA Colvin met with Administrator Jennifer Haas in the Skilled Nursing Building, as well as with Griselda T. Garcia, Administrator from Buena Vista Assisted Living. LPA Colvin informed Administrators of the purpose of the visit and obtained emergency contact information and current location for each relocated resident. LPA Colvin confirmed that 21 of the 38 residents from Buena Vista have temporarily relocated to this facility, with 5 of the 21 residing in the Skilled Nursing building, and the others in the Assisted Living building. Facility has sufficient food and supplies to support their residents as well as the relocated residents, and Buena Vista has supplied additional items for residents' needs, as well as staff to continue to care for the residents. Buena Vista Administrator has possession of resident medications and files, but is working with the facility to ensure resident's medications are provided to them as prescribed by Beuna Vista staff on site, and there is at least a one-day supply on site. Buena Vista administrator is working on making copies of emergency files for residents relocated to this location to have on-site for staff if needed.

LPA Colvin obtained approximate locations of residents not relocated to this facility, who have instead gone home with friends or family until the evacuation orders are lifted and they can return to Buena Vista. LPA Colvin confirmed that residents were sent with their medications and personal effects, and Administrator Garcia is in contact with them regarding when they can return. LPA Colvin toured the facility and confirmed that the current census (including relocated residents) is well below capacity and that residents are no more than two per bedroom and are provided comfortable accommodations. No immediate health or safety concerns observed at this time.

An exit interview was conducted with Administrators Jennifer Haas & Griselda T. Garcia, and a copy of this report was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
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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