336403817-11-30-2023-18-AS-CNWE-CY3V85-20231130151209

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336403817
Report Date: 11/30/2023
Date Signed: 11/30/2023 03:12:14 PM

Document Has Been Signed on 11/30/2023 03:12 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:	CASA DEL VALLE		FACILITY NUMBER:	336403817
ADMINISTRATOR:	LORI LARSEN		FACILITY TYPE:	735
ADDRESS:	789 MAIN STREET		TELEPHONE:	(951) 487-6368
CITY:	SAN JACINTO	STATE: CA	ZIP CODE:	92583
CAPACITY: 14		CENSUS: 12	DATE:	11/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Pedro Zambrano, Program Director		TIME COMPLETED:	03:18 PM

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On 11/30/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Caregiver, Hilda Herrera who was informed of the purpose of the visit. LPA also met with Program Director, Pedro Zambrano and also spoke to Administrator, Valerie Fleming via telephone call. At the time of visit there was two #2 staff and eleven #11 residents present. LPA was informed that one resident went home with parents. LPA toured the facility inside and out with Hilda Herrera.

Tour included:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the census. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen drawer, available only to authorized individuals. Trash cans has tight-fitting lid. Dishwasher is used to clean and sanitize dishes. Fridge, freezer and all need appliances were present and shown to be in working condition and clean.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 74 degrees Fahrenheit.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide was tested and functioning properly. Smoke detectors were last tested on 8/11/2022 by Riverside County Fire Department. LPA observed additional linens and hygiene items.

Medication: Medications were labeled and stored in separate bins inside of a locked mediaction cabinet and are distributed according to physician orders. The first aid kit was complete.

Continue on LIC809-C

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CASA DEL VALLE	FACILITY NUMBER: 336403817
	VISIT DATE: 11/30/2023

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Continued from LIC809.

Bathroom: LPA toured resident bathrooms and observed bathrooms to be clean. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 119 degrees Fahrenheit.

Bedroom: LPA toured eight #8 out of #8 resident bedrooms and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting.

Laundry: Washing machine and dryer are all in good repair and sufficient for census. Cleaning supplies are stored away in the laundry room, inaccessible to clients.

Backyard: LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gate remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents. Fridge and Freezer are large enough to accommodate required perishable foods.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Random staff and residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility.

Interview: two staff and three #3 residents were interviewed.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Pedro Zambrano.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

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