336409400-8-6-2024-18-AS-JARA-D7VV9T-20240806161453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336409400
Report Date: 08/06/2024
Date Signed: 08/06/2024 04:15:49 PM

Document Has Been Signed on 08/06/2024 04:15 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:	MESA VERDE HOME		FACILITY NUMBER:	336409400
ADMINISTRATOR/ DIRECTOR:	MARYROSE KHAN		FACILITY TYPE:	735
ADDRESS:	29656 MESA VERDE CIRCLE		TELEPHONE:	(951) 309-3733
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92584
CAPACITY: 6		CENSUS: 6	DATE:	08/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Licensee, Mary Rose Khan		TIME VISIT/ INSPECTION COMPLETED:	04:25 PM

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Licensee, Mary Rose Khan who was informed of the purpose of the visit. At the time of the visit there was (5) staff and (6) clients present.

The facility is a two story home with (8) bedrooms and (3) bathrooms with attached garage. (4) bedroom and (2) bathrooms are for clients. No pools or firearms are being kept at the facility.

Infection Control: The LPA observed hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 114F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

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

FACILITY NAME: MESA VERDE HOME	FACILITY NUMBER: 336409400
	VISIT DATE: 08/06/2024

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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. The listed administrator showed proof of submission of renewal of certificate.

Record Review and Resident/Staff Files: LPA reviewed (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. (3) client files were reviewed. LPA reviewed all staff are accounted for on Guradian roster for fingerprint clearance.

Health Related Services/ Incidental Medical Services: All client medication was locked in a cabinet. LPA reviewed client medications for (3) client and found all medication listed on MARS and accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill 6/27/2024, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items.

Technical notes were issued for facility to have a written infection control plan, facility had reference material on COVID and infectious disease guidance. Technical note was issued for unlocked chemicals observed in the upstairs area, no client were upstairs at the time and staff locked the cleaners right away. The staff agreed to conduct an in-service with staff to lock chemicals when not in the immediate area. The staff schedule was incomplete and did not show night coverage, a technical note was issued and staff schedule was unable to be located at the time of the visit. (1) client file did not have client goals or IPP, the staff had documented daily notes on client's progress and a technical note was issued. The administrator agreed to send corrections to the above technical notes by August 20, 2024. No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

LIC809 (FAS) - (06/04)

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