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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403573
Report Date: 09/15/2023
Date Signed: 09/15/2023 11:37:19 AM


Document Has Been Signed on 09/15/2023 11:37 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:VILLAGE, THEFACILITY NUMBER:
336403573
ADMINISTRATOR:ROB TAKAMIFACILITY TYPE:
741
ADDRESS:2200 WEST ACACIATELEPHONE:
(951) 766-5116
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY:452CENSUS: 35DATE:
09/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Dwayne WhiteheadTIME COMPLETED:
11:45 AM
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On 9/15/2023, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Administrator Dwayne Whitehead who was informed of the purpose of the visit.

LPA conducted a tour of the facility's interior and exterior with Caregiver Esmeralda Becerra. During the tour, LPA observed the following:

The facility is made up of two (2) buildings. One (1) building is designated for independent living, and the other building is designated for skilled nursing and assisted living. LPA was informed that the facility has 35 rooms designated for assisted living. LPA observed fire alarm systems, carbon monoxide detectors and fire extinguishers throughout the facility. LPA toured the kitchen and observed that food was stored in a safe and healthful manner. A regular sample menu was available for review as well as menus for residents with special dietary needs. The facility had a 2-day supply of perishable food items and 7-day supply of non-perishable food items. Knives were secured in the kitchen. The facility has various activities available for resident leisure. During LPA's visit, the facility was having a barbecue in the patio to celebrate assisted living week. LPA observed residents in their rooms and in common areas. LPA observed that cleaning supplies were secured in storage rooms. Medications were stored in medication carts only accessible to the Licensed Vocational Nurses and Medication Technicians on duty. LPA toured a sample of the resident rooms. The resident bedrooms had the required furniture and functional lighting. LPA observed grab bars and nonskid mats in the showers. The facility had a supply of additional linen and extra hygiene items for the residents.

Continued on LIC809-C..

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023
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: VILLAGE, THE
FACILITY NUMBER: 336403573
VISIT DATE: 09/15/2023
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Continued from LIC809..

LPA also observed emergency supplies and complete first aid kits. Outside shaded seating is available for resident use. Indoor and outdoor passageways are free of obstruction. The facility's last fire drill was conducted on 8/29/2023.

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 Whitehead.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC809 (FAS) - (06/04)
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