336408630-9-20-2023-18-AS-JROO-CVUMWN-20230920095839

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336408630
Report Date: 09/20/2023
Date Signed: 09/20/2023 09:58:42 AM

Document Has Been Signed on 09/20/2023 09:58 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:	HAZEL GUEST HOME II		FACILITY NUMBER:	336408630
ADMINISTRATOR:	HAZEL A. BUTARDO		FACILITY TYPE:	740
ADDRESS:	24629 SUPERIOR AVENUE		TELEPHONE:	(951) 247-9355
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92551
CAPACITY:	6	CENSUS: 3	DATE:	09/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee Hazel A. Burtado		TIME COMPLETED:	10:15 AM

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On 9/20/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver, Myrna de Jesus who was informed of the purpose of visit. Licensee Hazel A. Burtado arrived shortly after LPA entered the facility. During the visit, there was two (2) residents and one (1) staff present. LPA was informed that one (1) resident was at day program.

The facility is approved to care for four (4) non-ambulatory and two (2) ambulatory elderly residents. LPA toured the facility's interior and exterior with Licensee Burtado. The facility is made up of four (4) resident bedrooms, two (2) resident bathrooms, a kitchen, dining/living room, staff room and garage. During the visit, LPA observed the following:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. LPA observed food supply met the requirement for a 2-day supply of perishable food and 7-day of non-perishable food items. Cleaning solutions, chemicals and knives are stored in a kitchen cabinet and secured with master lock.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. The facility has board games, activities, and puzzles available for residents. LPA observed both residents in the living room. Fire extinguisher is charged and mounted in the living room.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. Carbon monoxide and smoke detector were tested and functioning properly.

Continued on LIC809-C..

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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: HAZEL GUEST HOME II	FACILITY NUMBER: 336408630
	VISIT DATE: 09/20/2023

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Continued from LIC809.

Centrally Stored Medications: LPA observed two (2) first aid kits with required components and manuals. Medications were secured in a file cabinet stored in the dining room. LPA reviewed physical medications for the residents as well as the Medication Administration Record (MAR) used to log administration of residents’ medications. No discrepancies discovered.

Bedrooms: Resident bedrooms were clean and each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with a grab bar in the shower. The residents' bathroom hot water temperature measured at 120-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the residents in care.

Laundry/Garage: LPA observed laundry room and garage to be clean. Washing machine and dryer are in good repair. Emergency food, water, additional linen, PPE, and incontinent supplies are stored in the garage.

Records: Staff present has a criminal record clearance on file, are associated to the facility and have current CPR/First Aid certification.

Yard/Outside Area: Covered patio seating is available for residents. A brick wall secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

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 Licensee Burtado.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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