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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412338
Report Date: 06/29/2023
Date Signed: 06/29/2023 08:15:36 PM

Document Has Been Signed on 06/29/2023 08:15 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CHARLINE'S ADULT RESIDENTIAL FACILITY IIFACILITY NUMBER:
336412338
ADMINISTRATOR:WILLS, CHARLINEFACILITY TYPE:
735
ADDRESS:24956 SPRINGBROOK WAYTELEPHONE:
(951) 246-7339
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 4CENSUS: 4DATE:
06/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:25 PM
MET WITH:Charaline WillsTIME COMPLETED:
08:15 PM
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Licensing Program Analyst (LPA) Cheryl Goodrich conducted an unannounced annual visit. LPA met with the Administrator Charline Wills at the front door and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility follows California Code of Regulations, Title 22, Division 6. Facility is approved for four (4) ambulatory residents.
Physical Plant: front entrance, interior and surrounding exterior were clean and in good repair with no pathway obstruction; facility temperature read at 68 degrees. There are two (2) resident bedrooms, each containing 2 beds, lamps and televisions for the residents to watch tv. The bedrooms were observed to have clean linens, dresser drawers and closet space for both residents. The residents' main restroom water temperature read at 115.3 degrees; there were no bodies of water on premises; there was sufficient lighting and mattress pads in all the residents' bedrooms; fire alarm and smoke carbon monoxide detectors were in working order. Facility does not house firearms and/or ammunition on grounds.
Food Services: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available to residents.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2023
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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CHARLINE'S ADULT RESIDENTIAL FACILITY II
FACILITY NUMBER: 336412338
VISIT DATE: 06/29/2023
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Medication/Facility Records: Medications were observed to be labeled and in a locked place that is inaccessible to residents. All staff subject to a criminal record review obtained fingerprint clearance and/or an exemption. Staff responsible for direct care and supervision have current First Aid / CPR training. Administrator has completed a written admission agreement, current medical assessment and needs and service plan with each resident. Administrator handles resident cash resources and documentation log, and receipts were in place.
Technical Violations: A technical violation was issued due to the Physician’s Report not being available at the site. The Administrator was able to provide a copy of the facesheet during the time R3 was seen by their physician on 06/05/23. A technical violation was issue due to Administrator not having a current Administrative Certificate on file. Administrator states she completed the training in March 2023 and provided receipts of course training and mailing of certificate.
Summary: Based on today's visit, no deficiencies were observed at this time. One technical violation was issued for no current physician report for 1 out of 4 residents. One technical violation for not having a current Administrator Certificate on file. The Administrator was able to provide proof of completion of both. An exit interview was conducted with Charline Wills and a copy of this report was printed Signature below confirms receipt of these rights.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC809 (FAS) - (06/04)
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