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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408880
Report Date: 08/29/2024
Date Signed: 08/30/2024 08:18:08 AM

Document Has Been Signed on 08/30/2024 08:18 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ABELLA ADULT RESIDENTIAL FACILITY IVFACILITY NUMBER:
336408880
ADMINISTRATOR/
DIRECTOR:		LOURDES G. ABELLAFACILITY TYPE:
735
ADDRESS:16515 DARTMOOR CIRCLETELEPHONE:
(951) 208-2369
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 6CENSUS: 4DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Staff Teresita UrquiaTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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On 8/29/24 Licensing Program Analyst's (LPAs) Valerie Flores, Abdoulaye Zerbo, and Andrei Castillo conducted an unannounced one (1) year required visit. LPA's were granted entry by caregiver, Teresita Urquia, who was informed of the purpose of visit. At the time of the visit there were one (1) staff, and four (4) residents present. Staff present was observed to have obtained proper fingerprint clearance and was associated to the facility. LPA's observed the following during today's visit:

LPA's conducted a tour of the facility with staff member, Teresita Urquia. The Facility was operating within the scope outlined in their license. The physical plant contained four (4) resident bedrooms, one (1) staff bedroom, and three (3) bathrooms. Resident bedrooms had the required bedding, furniture, and lighting. The facility has a dining room, kitchen, living room, and a gated backyard. Indoor and outdoor passageways were free of obstruction. There were no bodies of water located on the property. The facility has more than a two (2) day supply of perishable foods and seven (7) day supply of non-perishable foods. Facility stores emergency food and water inside the facility. Water temperature measured at 107-degree Fahrenheit meeting within the required limits. LPA's observed a refrigerator with perishables and non-perishables for staff located in the garage. Dishes and utensils were in sufficient supply and in good repair. Knives and sharp items are located in the kitchen in a locked cabinet. Disinfectants and cleaning solutions were secured in a locked cabinet under the kitchen sink. Centrally stored medication was located in a locked cabinet in the living room area. Facility files are located in a locked closet near the entrance. The smoke and carbon monoxide detectors were tested and were observed to be operable. LPA's observed a charged fire extinguisher mounted in the dining room. Facility maintained magazines and other craft materials to engage residents in activities outside their room.


Continuation on LIC809C...

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ABELLA ADULT RESIDENTIAL FACILITY IV
FACILITY NUMBER: 336408880
VISIT DATE: 08/29/2024
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Staff files reviewed included but not limited to a criminal record clearance, required training, personnel records, and valid first-aid/CPR certification. Administrator files contained criminal record clearance, valid administrator certificate, valid CPR/first-aid training and additional required training's. Resident files included but are not limited to signed admission agreements, personal rights, physician reports, and current CEDAR. Facility sketch, personal rights, and emergency disaster plan is posted on a wall near the garage. According to staff, Teresita, there are no firearms or ammunition on the premises.

During today's visit, LPA's did not observe any immediate violations or concerns. An exit interview was conducted, and a copy of this report was reviewed and provided to staff, Teresita Urquia.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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