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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412255
Report Date: 12/28/2023
Date Signed: 12/28/2023 05:09:17 PM


Document Has Been Signed on 12/28/2023 05:09 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:LIFESTYLE HOME CARE IIFACILITY NUMBER:
336412255
ADMINISTRATOR:MARY MATEASFACILITY TYPE:
740
ADDRESS:5417 SKYLOFT DRIVETELEPHONE:
(951) 360-1622
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:6CENSUS: 6DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Mary Mateas, AdministratorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced annual required visit. LPA was greeted and granted entry to the facility by Administrator Mary Mateas . LPA explained the nature of today's visit.

LPA accompanied with Ms Mateas, conducted a general overall inspection, which included, but was not limited to the following:

Physical Plant: The facility was not operating over capacity or beyond any conditions and limitations on the license. There are no pools and other bodies of water located on the premises. Facility is being maintained at a comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Hot water temperature was measured at 110 degrees Fahrenheit in all resident bathrooms. There are grab bars for each toilet, bathtub and shower used by residents. The facility smoke detectors and carbon monoxide devices were tested and found to be in working order.

Food Service: There is a minimum of one week supply of nonperishable foods and 2 days of perishable foods.

Care and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: LIFESTYLE HOME CARE II
FACILITY NUMBER: 336412255
VISIT DATE: 12/28/2023
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Record Review: LPA requested and reviewed three (3) resident and one (3) staff files. LPA reviewed staff files for current CPR/1st aide certificates, TB results, and required training's.

Administration: LPA did not observe any excluded individuals on the premises at time of visit. The Administrator appears to be on the premises a sufficient number of hours to manage and oversee the business operation.

Medical Related Services: Prescriptions and non-prescription PRN medications contain a signed and dated written order from a physician. Medications are centrally locked in the staff office and inaccessible to residents in care. Medications are being administered as prescribed by physician's directions.

No deficiencies cited. An exit interview was conducted where this report was provided and discussed with Ms Mateas.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
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