336408880-8-9-2023-18-AS-JROO-CUJR88-20230809124731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336408880
Report Date: 08/09/2023
Date Signed: 08/09/2023 12:47:35 PM

Document Has Been Signed on 08/09/2023 12:47 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ABELLA ADULT RESIDENTIAL FACILITY IV		FACILITY NUMBER:	336408880
ADMINISTRATOR:	LOURDES G. ABELLA		FACILITY TYPE:	735
ADDRESS:	16515 DARTMOOR CIRCLE		TELEPHONE:	(951) 208-2369
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92551
CAPACITY:	6	CENSUS: 4	DATE:	08/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Caregiver Teresita Urquia		TIME COMPLETED:	01:15 PM

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On 8/9/2023, at 11:30 a.m., 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 Teresita Urquia who was informed of the purpose of visit. The facility is approved for six (6) ambulatory clients ages 18-59. During the visit, there was one (1) staff present and LPA was informed that clients were at day program.

LPA toured the facility’s interior and exterior and observed the following:

Kitchen: LPA observed kitchen area to be clean. Food is stored in a safe and healthful manner. LPA observed the facility had more than a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Knives/sharp instruments are secured in a locked kitchen cabinet under the sink.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. LPA observed a working television and several board games and activities available for clients.

Hallway: LPA observed hallway to be clean with no pathway obstruction. Facility has a fire alarm system. 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: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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: ABELLA ADULT RESIDENTIAL FACILITY IV	FACILITY NUMBER: 336408880
	VISIT DATE: 08/09/2023

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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications are secured in kitchen cabinet. LPA observed that although medications are secured, Caregiver Urquia had a difficult time unlocking the medication cabinet using the magnetic lock. Technical advisory issued to replace/repair magnetic lock. LPA reviewed physical medications for Client #1 and Client #2 as well as Medication Administration Record, no discrepancies discovered.

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

Bathrooms: Bathroom has a working toilet, wash basin, and was equipped with a grab bar in the shower. The hot water temperature measured at 115-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the clients in care.

Laundry/Garage: LPA toured the laundry room and garage. Washing machine and dryer are in good repair. Emergency food supplies, water, additional hygiene supplies, linen, towels and incontinent supplies are stored in the garage.

Records: Staff present have a criminal record clearance on file and are associated to the facility. Staff training is up to date.

Yard/Outside Area: Shaded seating area is available for clients to sit and relax. 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.

Residents’ Cash Resources: The facility safeguards clients’ cash resources. LPA reviewed Record of Client’s/Resident’s Safeguarded Cash Resources (LIC) 405 for all clients and did not discover any discrepancies.

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 Caregiver Urquia.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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