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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412341
Report Date: 01/09/2025
Date Signed: 01/10/2025 11:25:30 AM

Document Has Been Signed on 01/10/2025 11:25 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MAYBERRY HOUSE, THEFACILITY NUMBER:
336412341
ADMINISTRATOR/
DIRECTOR:		DEBORAH STANGELFACILITY TYPE:
735
ADDRESS:40678 MAYBERRY AVETELEPHONE:
(951) 652-3556
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 4CENSUS: 3DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Breanna Bridges - Facility ManagerTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA), Ferrer Sabarias made an unannounced visit to the facility for the purpose of conducting a required annual inspection. LPA was greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPA met with House Manager Breanna Bridges, she was notified of the purpose for the visit.

Physical Plant: The facility is a one story home with four (4) bedrooms and three (3) bathrooms, including an attached garage. The Licensee is operating the facility within the conditions and limitations specified on the license. Clients appear to be protected against immediate hazards. Outdoor and indoor passageways are kept free of obstruction. No pool or body of water was observed on the property. According to the House Manager Bridges, there are no weapons kept in the home. Disinfectants, cleaning solutions, and poisons were locked and inaccessible to clients in care. A comfortable temperature was being maintained in the home. There was sufficient lighting in all rooms to ensure the comfort and safety of clients. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. The smoke and carbon monoxide alarms were tested and found to be operable. There are 2 fire extinguishers last maintenance date was 10/25/2024. The interior and exterior areas of the home were observed to be clean and safe.

Food Service: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. The kitchen was observed to be clean, and the hot water temperature was 119.5°F.



Continue LIC 809C…
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Ferrer Sabarias
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MAYBERRY HOUSE, THE
FACILITY NUMBER: 336412341
VISIT DATE: 01/09/2025
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Continued from LIC 809…

Record Review: Two (2) Staff files were reviewed and had required training; including, but not limited to, first aid training and emergency procedures training. Staff present had the required criminal record clearances. Three resident files were reviewed an Individual Program Plan (IPP) and Medical Assessment (Physician's Report) was on file for clients in care. House Manager Breanna Bridges has an active Administrator's certificate, which expires on 10/12/2025. An earthquake drill was completed on 12/9/2024 and fire drill was completed on 12/1/2024.

Medication: Medication was reviewed for three (3) clients in care. All medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to clients in care. Medications and medication documentation was observed to be organized and monitored.


This report was reviewed with House Manager Breanna Bridges and a copy was provided. No deficiencies were cited at time of inspection.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Ferrer Sabarias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
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