336410667-1-29-2025-18-AS-SJEN-DDDUMT-20250129144252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336410667
Report Date: 01/29/2025
Date Signed: 01/29/2025 02:44:35 PM

Document Has Been Signed on 01/29/2025 02:44 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:	DOLORES HOMECARE		FACILITY NUMBER:	336410667
ADMINISTRATOR/ DIRECTOR:	ANALISA CAYABYAB		FACILITY TYPE:	740
ADDRESS:	30758 BLOOMSBURY LANE		TELEPHONE:	(760) 202-6609
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY: 4	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	01/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Analisa Cayabyab, licensee		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Nilda Agtang, caregiver, and informed them of the purpose of the visit. At the time of the visit, there were three (3) staff members and three (3) residents present.

The facility is a one-story home with three (3) bedrooms and two (2) bathrooms, including an attached garage. There are no pools or known firearms on the premises.

LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 120°F. Fire extinguisher located at dining area has current inspection tag.

The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.

Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate.

Continued on LIC809-C....

Rikesha Stamps	TELEPHONE: (951) 212-0616
Seo Jeon	TELEPHONE: 951-248-0309
	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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: DOLORES HOMECARE	FACILITY NUMBER: 336410667
	VISIT DATE: 01/29/2025

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LPA reviewed files for four (4) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Three (3) resident files were reviewed and contained all required documentation.

All resident medications were securely locked. LPA reviewed medications for three (3) residents, confirming that all medications were dispensed per their prescription.

LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on January 5, 2025, which met department requirements. All facility exits were clear of obstructions.

No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC809 (FAS) - (06/04)

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