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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403573
Report Date: 09/04/2024
Date Signed: 09/04/2024 02:33:54 PM


Document Has Been Signed on 09/04/2024 02:33 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
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: 38DATE:
09/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:ASSISTANT LIVING DIRECTOR, MICHELLE FLORES, TIME COMPLETED:
02:40 PM
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On September 04, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with Assistant Living Director, Michelle Flores. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 52, but is operating 38 (741), Facility Type.

LPA Mixson toured the facility and made observations pertaining to the annual visit. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. The facility is a single-story building located at 2200 West Acacia Hemet Ca. 92545

Physical Plant: The facility phone number is (951) 766-5116 and it is operable. LPA Mixson observed a sampling of the living units and those sampled were equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations. LPA reviewed a sample of the restrooms and those sampled were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something" Ombudsman's and the "Personal Rights." The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked.

Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. The overall facility is clean, the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLAGE, THE
FACILITY NUMBER: 336403573
VISIT DATE: 09/04/2024
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The facility is made up of two buildings. One 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.

FOOD SERVICES: LPA Mixson 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 two-day supply of perishable food items and seven-day supply of non-perishable food items. Knives were secured in the kitchen.

DISASTER PREPAREDNESS: Last Fire Drill was conducted 2024 and are conducted monthly with the Fire Marshall, and training binder was made available for review.

RECORD REVIEW & STAFF & RESIDENT FILES: LPA review five staff files and five resident files. Files reviewed had criminal clearances and updated CPR and other training's. Resident files possessed required documents currently, for safe guarding belongs there is a safe with a code, and file for logging.

The facility has various activities available for resident leisure. LPA Mixson 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.

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 August 2024

There were no deficiencies observed or cited per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted and a copy of this report was discussed and given to Assistant Living Director, Michelle Flores

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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