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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411389
Report Date: 06/14/2024
Date Signed: 06/14/2024 03:27:47 PM

Document Has Been Signed on 06/14/2024 03:27 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:CASA MICHANAFACILITY NUMBER:
336411389
ADMINISTRATOR/
DIRECTOR:		NANCY MOQUETEFACILITY TYPE:
735
ADDRESS:29161 BRIDALVEIL LANETELEPHONE:
(951) 746-3416
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 5CENSUS: 2DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Licensee, Marcela HurtadoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 6/14/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to conduct an annual required inspection. LPA was greeted and granted entry by Caregiver, Fernando Guerrero who was informed of the purpose of the visit. Licensee Marcela Hurtado arrived during the visit. The facility has a fire clearance for five (5) ambulatory clients and serves adults ages 18 through 59.

During the visit, there was one (1) client and one (1) staff present and LPA was informed one (1) client was out in the community. LPA toured the facility with Caregiver Guerrero. During the tour, LPA observed the facility is made up of a two (2) story home with four (4) client bedrooms and three (3) bathrooms along with a kitchen, dining room, living room, two (2) staff rooms, and attached garage. LPA toured the kitchen and observed the area to be clean. LPA also observed the facility had a 2-day supply of perishable foods and 7-day of non-perishable food items. Food is stored in a safe and healthful manner. Medications were secured in a closet near the stairway. Client files reviewed had updated Individual Program Plans and signed admission agreements. Client bedrooms were each furnished with a bed, chair and night stand. Bathrooms have a working toilet, wash basin with toilet paper and soap readily available. Staff present have a criminal record clearance and are associated with the facility. Outdoor shaded seating area is available for the clients. There are no bodies of water on the premises. Indoor and outdoor passageways are free of obstruction. LPA observed charged fire extinguishers mounted throughout the facility, which were serviced on 11/20/2023. Caregiver Guerrero tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and this report was reviewed with Licensee over the phone and provided to Licensee Hurtado.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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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