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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412341
Report Date: 01/05/2024
Date Signed: 01/05/2024 04:09:31 PM

Document Has Been Signed on 01/05/2024 04:09 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
RIVERSIDE, CA 92507
FACILITY NAME:MAYBERRY HOUSE, THEFACILITY NUMBER:
336412341
ADMINISTRATOR:DEBORAH STANGELFACILITY TYPE:
735
ADDRESS:40678 MAYBERRY AVETELEPHONE:
(951) 652-3556
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 4CENSUS: 4DATE:
01/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:FACILITY MANAGER, FRANK DEAGULARTIME COMPLETED:
04:11 PM
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On January 05, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the required annual inspection and met with the Facility Manager, Frank Deagular introduced herself and stated the purpose of the visit. The facility file review was conducted in the office and forms were requested and received on site.

LPA Mixson toured the facility along with the Facility Manager and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single story home, located at 1504 Mayberry Ave Hemet, CA 92544. Physical Plant: The facility phone number is (951) 652-3556 and is operable. The LPA observed the residents bedrooms, and they are equipped with required furniture as per Title 22. The LPA inspected facility bathrooms, and the hot water temperature was tested and tested within regulations, and logged by Frank. The bathrooms were clean and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required postings such as "If you See Something, Say Something" the "Personal Rights" and the Ombudsman postings were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the resident and staff files and they were locked and inaccessible to residents in care. Medications: were locked and inaccessible to residents, and there was a 30 day supply. The overall facility is clean, the furniture is in good condition. The facility heating system and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly. Care & Supervision Facility has sufficient staff, three staff at the time of this visit and the staff were engaging the residents in an activity. Records Review: The LPA reviewed four resident files, and three staff files, and conducted three staff interviews, and four resident interviews. Previous Community Care Licensing forms were reviewed. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted and a copy of this report was given Frank Deaguliar, Facility Manager.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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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