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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411389
Report Date: 06/16/2023
Date Signed: 06/16/2023 11:52:42 AM

Document Has Been Signed on 06/16/2023 11:52 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:CASA MICHANAFACILITY NUMBER:
336411389
ADMINISTRATOR:NANCY MOQUETEFACILITY TYPE:
735
ADDRESS:29161 BRIDALVEIL LANETELEPHONE:
(951) 746-3416
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 5CENSUS: DATE:
06/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Victor ManzoTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Cheryl Goodrich conducted an unannounced annual required visit on 6/16/2023 at 8:52AM LPA was granted entry and met with Victor Manzo who was informed of the purpose of the visit. At the time of the visit there was (1) staff and (0) clients present.

Buildings and Grounds: The home is composed of six (6) bedroom which consist of two (2) staff bedrooms, four (4) client bedrooms, three (3) bathrooms, a laundry area, kitchen and dining areas, and a front/back yard area. The interior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Victor, there are no weapons stored in the home. Rooms, furniture, beds, mattresses appeared to be in good repair. The bedrooms are furnished, and privacy is available. The dining and living room areas are clutter free and in good condition. The LPA tested the hot water temperature, which was registered at 108.2 degrees Fahrenheit, which is within regulatory limits. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer are available and in working order.



Storage and Supplies: Medications is stored in the office area on the first floor near the staircase, inaccessible to any unauthorized individuals. Secured areas are available for facility files and client files. The first aid kit was observed to be available and complete and found in the laundry room. Cleaning supplies stored away in a secured closet, which is located under the kitchen sink. Linens, and equipment appeared to be in good repair and sufficient for approved census. A Fire extinguisher was available and fully charged.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps are stored under the kitchen sink, available only to authorized individuals.

Record Review and Resident/Staff Files: LPA reviewed all staff files and reviewed the facility's staff schedule. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed and possessed all required paperwork.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CASA MICHANA
FACILITY NUMBER: 336411389
VISIT DATE: 06/16/2023
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Health Related Services/ Incidental Medical Services: All client medication was locked in a medication cabinet. LPA reviewed client medications for (2) clients and found all medication listed on centrally stored lists and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency food supply in the office area, in a locked closet near the staircase.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E), Personal Rights, and Facility Sketch (LIC 999)



No deficiencies were cited during this visit. An exit interview was conducted where a copy of this report was provided to staff Victor Manzo.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC809 (FAS) - (06/04)
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